Speaker: Unionization improves physician, patient well-being

Key takeaways:

• Strikes have targeted wages and staffing as well as patient care and safety.
• In 2019, 7.2% of all physicians were union members.
• Hundreds of employee physicians in multiple organizations unionized in 2023.

BOSTON — Unionization may offer physicians advantages beyond improved salaries, and it may benefit patients as well, according to a presentation at the CHEST Annual Meeting.

“It’s important to think about what unions do and who they are for,” Geneva B. Tatem, MD, FCCP, a pulmonologist in the Detroit area, said during her presentation.

In 1935, the National Labor Relations Act (NLRA) enabled employees at private institutions to organize. It does not apply to independent contractors, supervisors or managers.

“That becomes important when we think about the profession of medicine,” Tatem said.

The main functions of unions include political advocacy, mutual aid and welfare, and collective bargaining, she said.

“One of the important constructs within the NLRA is that employers must negotiate in good faith with union representatives,” Tatem said. “It doesn’t mean they can get what they want, but it certainly does mean that there have to be good conversations.”

The history of medical unions

In 1934, 66 residents from 26 hospitals founded the Interne Council of New York.

“They didn’t have a salary, they had excessive hours, were working up to about 120 hours a week, and had shifts that were in excess of 50 hours, which is incomprehensible to us,” Tatem said.

In 1957, this group became the Committee of Interns and Residents (CIR), which still operates today.

The NLRA extended coverage to nonprofit hospitals in 1974. But in 1976, the National Labor Relations Board (NLRB) determined that members of the house staff were students, not employees, which shut down the unionization efforts of the time.

In 1998, CIR became affiliated with the Service Employees International Union, which now represents more than 1 million health care workers including physicians, advanced practice providers and nurses.

Then in 1999, the NLRB reversed its 1976 decision and classified house staff as employees again.

“Part of why we’re seeing a resurgence is because of their new status,” Tatem said.

Health care strikes during this era have had a variety of reasons, Tatem continued. The first major strike was in 1974, when house officers at Howard University picketed for 12 days in support of patient care and safety.

“They really wanted to upgrade laboratory services,” Tatem said. “They wanted better nursing coverage, and they wanted better malpractice insurance.”

Tatem called 1975 the “Year of Activism,” with residents and interns striking in New York City, Los Angeles and Cook County Hospital in Chicago over duty hours, wages and patient care.

As a result of the strike in New York City, calls were restricted to every third night. In Los Angeles, strikers won a 10.5% increase in their salary, but they turned half of those gains into a $1.1 million patient care fund that is still active.

“In Chicago, Cook County residents struck for 18 days,” Tatem said. “What they were looking for was an increase in Spanish language interpreters, IV teams, and more expedited X-ray and lab processing.”

House staff at public and private hospitals in New York City struck over the need for adequate staffing in 1981.

“This was actually one of the first strikes where retaliation against house officers started to become a major concern,” Tatem said. “The judge adjudicating that situation actually told them that if they did not report to duty, they would be terminated and they would lose a year of accreditation in terms of their certification for training.”

Residents at Boston Medical College went on a 3-day strike in 1997 over inadequate staffing as well. These residents also filed a suit against the NLRB, which led to the reclassification of residents as employees in 1999.

Tatem also cited the 2023 strike at Elmhurst Hospital in Queens, New York, over retroactive hazard pay for work during the COVID-19 pandemic.

“We often think about medical strikes as really being focused around money, and in particular salaries for trainees,” Tatem said. “Most of their strikes actually resulted in and were focused on staffing and patient care and patient safety issues.”

The impact of action

Tatem cited a meta-analysis that found no evidence that strikes had any impact on in-hospital patient mortality in 14 studies. She also cited a study that found a 5.5% reduction in patient mortality in California hospitals with nursing unions.

Another survey of 5,701 surgical residents included 690 residents from 30 unionized programs and 5,011 residents from 255 non-unionized programs. There was no difference between the groups in reported burnout, which Tatem said was not surprising.

“They were all burned out,” she said.

But more importantly, Tatem continued, the programs with unions saw improved housing stipends and vacation policies and decreased sexual harassment.

“For any trainee, this is an important positive impact on not only their learning environment, but their work environment,” Tatem said.

Tatem also noted that she was a fellowship program director for 17 years and that she has a lot of experience in speaking with fellows about their concerns and woes in the employment and economic market.

“When people dialog about unions not really having any benefit for residents, I take umbrage in that,” she said.

The percentage of physicians who belonged to a union increased from 5.7% in 2014 to 7.2% in 2019.

“It’s probably closer to 9% to 10% right now,” Tatem said, adding that 14% of all workers in the United States belong to a union. “And more importantly, residents and fellows collectively account for about 15% of our U.S. physician workforce.”

Considering these numbers, Tatem continued, resident unionization has an “incredible” impact, with the largest wave of advocacy for physician well-being since the 1970s over the past 3 years.

CIR has grown by more than 16,000 house staff members since 2019 for a total today of 31,000, almost doubling its size, Tatem said. This increase also is comparable to the size of the class that matched through the National Resident Matching Program in 2023.

“That’s extraordinary, and this is only one house officer union,” Tatem said. “There are multiple unions around the country that are both in private and public hospitals, so keep that in mind.”

Eight institutions that represent nearly 4,000 house staff have organized in California, Illinois, Massachusetts and Vermont since March 2021. Also, there have been 14 house staff unions that have formed at private employers since 2022.

Union prevalence varies across the country and is dependent on broader policy and political factors that impact collective bargaining as well as on local right-to-work labor laws. For instance, Tatem noted that New Jersey allows supervisors to unionize.

“What about employee physicians in practice?” Tatem asked. “Just like we saw a resurgence in house officer unionization, we’re now seeing growth in parallel to that of house staff for employee physicians.”

Approximately 75% to 80% of physicians are employees of hospitals or of private employer groups, including private equity companies.

In 2023, 400 primary care physicians at Allina Health in Minneapolis, 200 hospitalists at six Legacy Health hospitals, physicians at Salem Hospital Massachusetts and anesthesiologists at Cedars-Sinai unionized.

“Particularly in the [emergency room] and anesthesia world, about 25% to 30% of them are private equity owned,” Tatem said. “That’s why you’re seeing this movement in those specialties.”

Conclusions

Tatem said that unions allow for voice and agency, particularly in new areas for advocacy, such as institutions that sue patients for unpaid medical bills.

“That’s probably an area where unions can be of value,” she said. “Really put that voice out for patient care and patient safety all over again.”

Non-compete clauses are another potential area for contention, she continued, since they are important to employee physicians who are not in training anymore. Aggressive relative value units may drive unionization among employed physicians as well, she added.

However, Tatem cautioned physicians against just jumping into organizing.

“If this dialog is happening at your home institution, I think it’s obviously important to consult an expert,” she said.