Editor's Note: This presentation of Both Sides Now was recorded prior to COVID-19. While the pandemic is not mentioned in the discussion, the main premise of whether physicians should organize for change in working conditions seems relevant during these trying times.
This transcript has been edited for clarity.
Arthur L. Caplan, PhD: I'm Art Caplan and I want to welcome you to Both Sides Now. I think you're going to find today's topic—"Should Physicians Unionize?"—of keen interest. Residents, medical students, and many physicians ask me about unionization. Fewer hospital administrators ask me, at least in a positive sense, but it's a timely topic and one that I think will be worth your time.
Being a physician today clearly is a challenge. Physicians say that our healthcare system is draining them physically and emotionally. They feel that their knowledge is devalued sometimes. Their productivity demands leave them burned out and complaining of moral injury, meaning they work in a broken system. Some feel that they're being paid less despite an increasing volume of work. How can physicians make changes that will improve these work situations, make the system more amenable and tolerable, and make their jobs more rewarding?
Some doctors say that the key is to stop fighting the system as individuals and start organizing so that they become a stronger force. Some believe that the proper way to achieve that is to unionize. Are physician unions the answer? Are they the best strategy to pursue, both for doctors and patients? Can it even work? Is it ethical for doctors to try to use tools like strikes if they can't reach an agreement with management?
To answer these questions and the many others raised by the topic of unionization, I have two distinguished guests today. Wendy Dean has been a friend of mine for many years. She's a psychiatrist as well as the president and cofounder of an organization called The Moral Injury of Healthcare, which is dedicated to reducing moral injury, meaning harms that physicians feel they undergo because they work in a broken system or one that makes inequitable demands upon them. That term, I think, accurately describes many of the feelings that physicians currently have who are frustrated with the system. She prefers that term, as do I, over terms we sometimes hear, such as burnout, that seem to blame individual physicians for not being more resilient.
My second guest is Frank Proscia. He's the president of the Doctors Council, a union of physicians, dentists, and patients. The group advocates for physicians of various specialties through contract negotiations and other efforts. Dr Proscia is also a psychiatrist by training. I don't think we've had two psychiatrists on before—maybe the whole subject is driving us toward a mental health issue. Let me thank both of you for joining me today on Both Sides Now.
Understanding Healthcare Unions
So Frank, let me ask you. You've got this organization that you formed. How big is it? Tell me about it.
Frank P. Proscia, MD: We are a labor union for physicians and dentists. We have members in multiple states. We cover disciplines from A to Z, from anesthesiologists to zoologists—I'll just throw that Z out there—and everything in between. There are issues in the healthcare system, as you say, and we have thousands of doctors who are predominantly here in New York City. We also have members in Chicago and in other cities.
Members come to us and say they would like to unionize, they'd like to improve their lot, they'd like to improve their patient care and the doctor-patient relationship. As doctors become more and more salaried versus the independent practitioners, they tend to lose that autonomy and the control over the way they provide that care.
Caplan: How long has your group been around?
Proscia: It's been around over 60 years.
Caplan: A long time.
Proscia: I've not been around for those 60 years, but I've been around the past two decades.
Caplan: Wendy, has anybody ever approached you about being in a union? Has unionization crossed your path in your ordinary physician life?
Wendy Dean, MD: I was [practicing] a little bit before the big push for unions. I was also in a very rural area, so unionizing was not really considered. Since I started doing moral injury work, there's been a lot of discussion about whether to unionize and whether this will solve the problems. Really, the way I approach it is more from a place of caution. I'm not anti-union, but I do feel like physicians have many questions about it and it's a really good idea to get those all out on the table, have them explore what the answers are, and then decide for themselves whether that's the right approach.
Caplan: Well, that sounds eminently sensible. Let's see if we can undercut that over the next 20 minutes and push a little harder on some of these issues.
Frank, let me ask you something. One thing that is said to me frequently about unionization in healthcare is that it's unprofessional and that professionals don't unionize because they're management, or it is somehow inconsistent with being a physician to unionize. How do you respond to that?
Proscia: Legally, they're entitled; any salaried employee is entitled to be unionized. It's not something that's imposed upon them; it's the workers themselves.
Caplan: They're not forced to join.
Proscia: Exactly. The employees themselves decide whether they want to continue working in a situation that's harboring such ill will or disillusionment over time or whether they want to stand up and try to do something to change it. In the past, doctors tried to do things on their own. The problem with that is as an individual, it's a scream in the wilderness and you have no real power; but as a collective, as a group—look at groups such as the Greater New York Hospital Association.
Caplan: The trade group.
Proscia: Exactly. It's a trade group, which is very comparable to unions. They serve their members and they lobby quite well. I'm proud that the hospitals realized they need to do that to get the funding that they need and such.
Medical Societies vs Unions
Caplan: Can't the medical societies in different states play that role? Do they act as a kind of semi-union?
Proscia: Medical societies have always been considered the professional way of doing things. They do a great job in policy, legislation, and lobbying. The problem is that they've become so splintered over time. There are national groups, such as the American Medical Association (AMA), that encompass physicians from all specialties. In New York, there's the Medical Society of the State of New York (MSSNY), which encompasses physicians of all specialties, and they lobby quite well.
Those are two powerful organizations. There are comparable groups in other states also. The problem is that they are all subspecialty societies. Often, the person belongs to these splinter organizations and not to the MSSNY or to the AMA, and they lose that power that the collective can provide.
Caplan: I think AMA membership has been declining over the years.
Proscia: Yes, because a lot of—
Caplan: Lost to these specialty groups?
Proscia: Yes. I know the reason for that. I believe they have been taken up by unions. Often, these societies tend not to deal with the day-to-day work issues. A few years back, there was an issue regarding CME requirements and the mandates that various states were putting on the physicians.
When I've contacted the societies for assistance, they've said that it was a labor issue and they don't get involved with that. They've focused just on the policy and the legislation—what they consider the professional issues—because the societies grew up in the era of independent practitioners. Nowadays, more physicians are salaried and the worksite issues are prominent.
We are quite comparable to the medical societies because we encompass all physicians and all specialties. We are on a national level in that sense. We have jurisdiction within our international union to have any physician in any state be part of Doctors Council, but we handle the worksite issues especially well. The societies do handle the lobbying, the politics, and the legislation quite well—I'm not going to take that away from them. With both of us working together, I think the physicians can move forward a great deal.
Moral Injury and Physician Advocacy
Caplan: Wendy, before we get a little bit more in depth on the pros and cons of unions, we've mentioned a few times now the conditions being poor and the term "moral injury." What is it about the current system that is at least surfacing the topic of unionization? What do you mean by moral injury? What sort of problems are there in the system?
Some of our viewers are going to be thinking that they have a practice and are salaried, [so] they are not outraged, harmed, or hurt. Others may be thinking, "No, that's not my experience." What are we talking about here that might be triggering this discussion?
Dean: I think what's happened over the past couple of decades, at least, is that as physicians have become less and less engaged in the conduct of medical practice and the business side of medical practice, and as it became much more complex to manage the reimbursement side, we divorced ourselves from that side to some degree.
Caplan: Gave it to MBAs?
Dean: We gave it to MBAs in part, at least. I think we believed that we would still have clinical decision-making. As time has evolved, we've become less and less engaged; we're less often at the table where those decisions are made. What that ends up doing is that there are decisions, legislation, and regulations that are continually being piled on that get between us and our patients.
Every physician and clinician who is out taking care of patients took an oath to put that patient first. It comes before our lunch, it comes before our sleep, and it comes before we go to kids' birthday parties or anniversary dinners. Every time that we have to take care of the electronic medical record instead of our patient, we can't look them in the eye. Every time we have to call the insurance company and ask for a prior authorization to do an MRI or a CT scan or get a medication that we know our patient needs, we're choosing to put as a priority that electronic medical record, that insurance company, or our healthcare system rather than our patient.
Caplan: Do you think medicine is slowly—or rapidly—becoming a business rather than a profession?
Dean: I think it is definitely a business. I think there are professionals in it who are trying very hard to remain professionals. I don't think the two are mutually exclusive, but I think we need to start working together in a more effective way so that clinical care and the patients' needs continue to be the priority rather than profit of the bottom line.
Caplan: Frank, when you're out there and you're thinking about some of these conditions that upset practicing physicians, and maybe the patients as well—I certainly hear people say, "My doctor never looks at me; they're staring in the computer during the visit." —what sort of questions do physicians ask you about unionization? What sort of concerns do they have, pros and cons? What bothers them and what interests them?
Proscia: As Dr Dean speaks about, there's disillusionment in medicine. They've lost the autonomy, they're being dictated that they have to follow certain procedures in a hospital, they have to make sure they bill, they have to order tests so they can get money for that. There are things that doctors don't want to do. All they're concerned about, as you say, is treating the patient the best way they can. They've been taught. It's in their soul; it's engrained within a doctor. It's a service profession; they're all mission-driven.
The problem is that when the business aspect of medicine starts to affect them, it starts to erode at that. Some people [may be] clinically depressed. They become hopeless and think that there's no way out of this. Sometimes they don't even recommend going into medicine to people who are thinking about going to medical school.
Caplan: I do hear that.
Proscia: We ask our doctors, "What can we do as a union to help you?" Several years ago, they told us they wanted to be involved with the patient care decisions. They wanted to understand the business aspect of the facilities. They were interested in and wanted to take care of or lead the way on quality in terms of patient care.
After that, we incorporated within our agreements here in New York City something that's called the Collaboration Council. This is a rarity in any system throughout the United States. This is where we have monthly meetings and quarterly meetings on the system-wide level of the frontline doctors meeting with the C-suite—the CMO, the COO, the CFO, the CNO—and everyone rolls up their sleeves. It's a safe space [to ask], "What can we do to make things better?"
Caplan: I can imagine some management being supportive and saying, "We'll work with you if you're the voice." I know some CEOs who I doubt would be dancing down the street to share in that opportunity. What makes you think that you can grow this movement when you're facing off against highly profitable for-profit and not-for-profit chains? They're not looking to shake up the style of management that they have, and they may be happy that the MBAs are in there and kind of watching the bottom line that way as managers. What makes you think it's implementable in a broad way?
Proscia: It's the power of the white coat. It's the doctors that bring in the billings. It's the doctors that have the doctor-patient relationship. It's not the people in the C-suite alone. It's a teamwork effort by everybody. Obviously, the people with the MBAs know how to run a business, but they have to understand that they can't disrespect the doctors here. The doctors know healthcare; they know the patients. You have to listen to the doctors. And the ones who understand that, the ones who sit down and, as I said, roll up their sleeves, those are the ones who are making gains and the patients [will benefit].
Is It Ethical for Physicians to Strike?
Caplan: Wendy, one of the tools that you have when management might be a little recalcitrant and [balk at things]—or worse, at the prospect of a group bringing collective pressure—is striking. I think that's probably the core moral question around unions. In some ways, I don't think people are necessarily opposed to groups working together, but when things don't work out or you're not getting attention, whether you're a doctor, an airline pilot, or an air traffic controller—I brought them up as a broken union, though many years ago—you sort of deploy this weapon. What's your view about that?
I'll add to the question. I was asked recently what my view was of doctors going on strike in Hong Kong to protest against sending patients to them from the rest of China, worrying about the spread of the coronavirus. The simple question was, is it ethical for doctors to strike in an epidemic?
Dean: I think that is one of the questions that physicians struggle with when they consider unionizing because, as we said, we take an oath to put our patients first. If we are then faced with the dilemma of considering whether we are going to put ourselves first by going on strike, that is a very difficult needle to thread for a lot of physicians. I think there are probably ways that it can be done safely, that it can be done effectively to bring management to the bargaining table, but it is no small feat. Short of that, there may not be resolution to some challenges.
But in answering the last question that you asked Frank: As an organization, we've been looking very hard for those facilities that are doing well and that are treating their physicians well, so their physicians are happier. It seems as though when you match a dyad of a physician leader with an administrative leader, and the physicians manage the clinical care and the administrators manage the business side but they work together, that's really where the sweet spot happens.
Caplan: Well, I'm going to put the strike question to you. Has your union ever gone on strike? Have you had slowdowns or other labor actions?
Proscia: The union doesn't decide if there's going to be a strike; it's the doctors themselves. They speak through the union. Number two, we've been around 60-plus years, as I said. In all those years, we've had a number of strike votes but there was only one strike. I believe it was back in 1991 at one facility, but that was because the situation in terms of patient care, safety, and staffing was [so] deplorable that the doctors said they had to stand up because—
Caplan: For the patients.
Proscia: For the patients. And the strike only lasted, I think, less than 2 days. It was something that the employer realized they just couldn't maintain. But the point is that they chose to strike because it would be worse to have the situation continue.
Caplan: You don't think Wendy's concern that putting the doctors' interests ahead of the patients' drove that particular action?
Proscia: No. I believe that the doctors are making most of their decisions on the basis of patient care issues.
Caplan: That was a long time ago. Wendy, are you concerned that even now, when we listen to some of the conditions that might lead doctors to unionize, they may have the impact on patients in mind but they're also thinking, My schedule's crazy, I'm overworked, I don't like the task that I'm assigned? They might indirectly hurt patients; I'm not arguing against that. But do you worry that physician interests drive decisions about labor actions?
Dean: We can't discount that that might be true. There are facilities where physicians are getting 25%-40% reductions in their salary. They're being asked to see larger panels of patients. It does dovetail with the patient-safety issue because if you're seeing 60 patients in a day, you're probably not doing as thorough a job as you would like. There will be a time when we are saying, "I can't sustain my loan payments at this salary." We may need to think about taking further action. We may need to think about work slowdowns.
Caplan: I'm just curious about your views. I'm management, and I'm thinking that doctors are not going to strike. They've got the Hippocratic Oath and a commitment to put patients first. I don't have to deal with them like I might a different kind of a union, let's say, where they could decide that they're going to close the department stores, walk away from online marketing, and close down some kind of service. People might not like it, but they wouldn't die or become harmed. Do you think doctors have the stomach to really be a union or is that just an old-fashioned sense of union?
Dean: What I think is changing now is that patients are becoming aware of the challenges that doctors are facing, and they are becoming aware that it's not always the physicians who are the bad guys in this. There are plenty of union patients who might be willing to stand up for the doctors. I think there are certainly a lot of challenges to be aware of, but I think the ground is shifting as far as the collaboration and the alliance between physicians and their patients.
Caplan: Frank, I mentioned that students and residents sometimes ask me about unions. Do you see any shift in attitudes about collective-action unionization based on age? Is it an older-generation thing, younger-, or is it mixed? Or doesn't it matter?
Proscia: I do see that students and residents tend to be more active. They want to advocate, they want to stand up and have a rally or to [march on] Washington. They like to do things like that. It really depends on the culture of the facility itself. I know a lot of doctors at a lot of facilities around my age who appreciate what unions are. I don't understand where they get that attitude from; is it because they were in a union at one time themselves...
Caplan: Doing something else, yes.
Proscia: ...and they went into medicine later on in life? That's the problem with physicians trying to join a union nowadays. They go from college to medical school to residency and right into the profession. They've had no idea what a labor union does or what labor unions have achieved for the 40-hour work week, weekends off, working conditions, and child labor laws. Unions have done so much.
Now, as the profession is becoming more salaried, they're being treated like this is the Industrial Revolution. The business of medicine has changed that, little by little, even physicians may be weaned out of medicine for cheaper labor to take over.
Will Physicians Be Punished for Joining Unions?
Caplan: Are either of you concerned that if we see more unionization then someone's going to come along and say that nurse practitioners or a cheaper form of provider will replace some of the specialists with nonspecialists, more generalists, or cheaper salaries? Does that worry you in trying to promulgate unionization—that there could be either retribution or a substitution with less well-trained people?
Dean: I don't think we need to wait for unions for that to happen. I think that's already happened.
Proscia: Right.
Dean: We saw it in the emergency room, in the urgent cares out in Illinois.
Proscia: That's why doctors have to start standing up now. That's why they have to do the collective action. They have to go out in groups to the politicians and talk to community groups. [The community is] on your side, they know you're fighting for them, and they will back your play, but they need the doctors to lead the way.
Caplan: Let me challenge that slightly. I think you're right about union accomplishments—history shows that—but unions are shrinking. We have a lot of folks who are in states that don't want to hear about unions. It's hard to organize industries these days, just in general, to get in and get something done. It's politicized unionization. I'm not sure everybody in the current administration or Congress would be applauding the idea of broadening out a physician union. How would you respond to that?
Proscia: I think people are listening to the fake news. The problem here is that we have doctors who join the profession, get a letter that says they're now employed or they get an individual contract, but when there's an issue with that contract or the appointment letter, the doctor is in a room now with the chair, maybe with a few lawyers, and some people from HR, and they're fighting the system to try to get their way.
A union contract is a legally binding agreement, which really levels the playing field. You, as an individual, are not dealing with the system anymore. It's you as a collective with the hundreds of thousands of doctors behind you, all fighting. Doctors and the employer are held accountable with the collective bargaining agreement. They decided that agreement by consensus. Both parties sign off on that agreement and it essentially says, "I would be willing to give this for that." And the other side says, "We'll accept this for that."
Is every agreement 100% ideal for both parties? No, it's not. It's not a compromise; it's a consensus. That means everybody antes up, everybody agrees that we'll move this far forward and they'll be remunerated in this fashion, but they understand that there will be another contract negotiation 3-4 years down the line, and it's a stepwise improvement. At least now doctors will look back and say, "Okay, I may not have gotten to 100%, but you know what? The system isn't 100% hopeless. I've achieved this, next time I'll achieve more."
Caplan: Does that description, Wendy, make you worry that the individual doctor might lose more power, more authority, or more moral legitimacy in trying to yield to the group?
Dean: I worry about a couple of things. I worry first that if the union isn't run by physicians, then physicians may risk losing the sense of autonomy and the sense of agency that are sadly lacking right now. The other thing that I worry about is what the union can bargain with and what you can use in your collective action.
For example, it's very easy to come to an agreement about labor hours, but we've shown time and again that cutting down residence hours doesn't really help with burnout once it's been in place for a couple of years. What it does really impact is continuity of care for patients. We have to be exquisitely careful about what our unintended consequences are as we start moving these levers, and those would be my real concerns.
Mobilizing Physicians to Move Medicine Forward
Caplan: I'll ask you to follow up with that, moving toward the end of our discussion for today. Unions have been around in history and have done things in many sectors that have been to the good of workers and the public. Whether you're pro- or anti-unions in this area, that's a history that's real; it's labor history. But short of a union, if you want to get people to pull together, what ideas do you have?
Dean: We've set up a nonprofit as a place for people to come together and assemble as a collective. That requires people being (1) willing to do the work and (2) willing to come together and—
Caplan: That sounds like a club. What is it?
Dean: It's a group of people who are trying to move the needle in the same general direction to address prior authorization, to address quality standards for clinicians.
Caplan: And these are based at an institution or are national or regional?
Dean: Right now we're still assembling. We're all of about 12 months old now, but we are also working under another umbrella organization, which is pulling together all of these small nonprofits and people who want the same thing but are scattered all over the country. It is probably a higher level of inertia to overcome, to assemble outside of a union, but I think it can be done.
Caplan: Would you let Frank come and talk to them?
Dean: Absolutely. Absolutely.
Caplan: There's a lot of recruiting around there.
Dean: Absolutely. I think physicians really need to explore all of their options. I think we're all working, both Frank's organization and mine, toward the same end, which is to allow physicians to take better care of their patients without having a lot of wedges in between the doctor and the patient.
Caplan: Frank, I'm going to give you a final question or comment here, but it's coming in a different direction from what we've talked about so far. I was listening to a radio report the other night, about automation. There are plenty of jobs that experts in automation or artificial intelligence think might be replaced by at least an algorithm, if not a robot, down the road. Is that on your mind as you look forward?
I know what the issues are today in terms of people complaining, but if you're a pathologist or a radiologist, you may be thinking, I'm going to get replaced. They're going to farm this out to a reader and an algorithm. Do you see that becoming an issue down the road for unions to worry about, the automation of the healthcare workforce?
Proscia: Well, it's not something for the unions to worry about. I think it's something that the physicians themselves should be concerned about. We all know that machines, AI, or any of the new technology can do wondrous things, but without the physician and the human aspect to it, it could be misinterpreted. Remember, machines are only as good as the people who program them, and people sometimes make mistakes. So we always need the physician there.
This really is a discipline; it's a profession, as I said. It's like being a religious individual. It's a calling. A person who desires to help people, like a physician, like a dentist, like a healthcare provider, you can't replace that with a machine.
Dean: I agree that healing happens in the context of relationship. What we should be focusing on is technology that facilitates that relationship and doesn't replace it.
Caplan: I happen to agree with both of you. I happen to disagree that it's not going to become a big issue down the road, although maybe not in the next 5 or 10 years. Automation, even if you're taking away some of the empathy, some of the intuitiveness, some of the caring, you know how our management can be. If it's cheaper, maybe they will go in that direction. We'll have to see if patients can be made alert to join with healthcare providers to maybe not go down that path.
Dean: We have a great example of how that's worked: electronic health records.
Caplan: Yes, right, fair enough. Maybe not the ideal solution there. I think that's true.
Well, I think both of you shed a great deal of light on this contentious and complicated question. I told you just before we started that I wasn't sure what I thought about the whole unionization issue. I'm still not sure what I think, but you've given me more reasons to be confused, and that is part of the point of our doing Both Sides Now.
I want to thank you both for spending some time with us. You really had good insights on this, and I think this question is going to be around for some time to come in the immediate future.
I'm Art Caplan and I want to thank you for watching Both Sides Now.
Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.
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Cite this: Arthur L. Caplan, Frank P. Proscia, Wendy Dean. Is It Finally Time for Physicians to Unionize? - Medscape - Apr 28, 2020.
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