Can unions lead to better patient care?

Facing a budget crisis, the Cook County (Ill.) government closed clinics and laid off hundreds of doctors and nurses. In response, a majority of physicians involved once again signed cards to join a union. Is it the right response?

Reply:

The question of whether it is ethical for physicians to join a trade union is frequently confused with a variety of secondary questions. Often individuals who discuss these issues in medical journals introduce their attitudes about trade unions in general, the history of specific unions, the social role of unions within the U.S. or opinions about specific trade union tactics, for example, strikes. These issues, while engrossing, are not the nub of the debate. Removed from its more inflammatory aspects, the question is whether it is ethical for physicians to bargain collectively the conditions of their practice.

The first part of this question asks whether the individual physician has a responsibility to his or her patients outside of the clinical interaction. The AMA's Principles of Medical Ethics notes that "A physician shall, while caring for a patient, regard responsibility to the patient as paramount." I would emphasize that the responsibility does not stop there, by quoting the preamble to those principles: "As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self."

In this country, physicians clearly have found it to be ethical if not imperative to advocate collectively for themselves and their patients for well over a century. The AMA, founded in 1847, was designed, through collective action, to raise and standardize the requirements for medical degrees and collectively impose a single code of professional ethics. In the end the effort was largely successful.

The second component of the debate today is related to the acceptable forms of organization and how to apply individual ethical precepts to collective activity. Clearly these organizations should reflect the environment within which they operate and should foster the ethical principles of the profession.

With the explosion of medical technology during the last 50 years and its increasing cost and complexity, individual physicians concerned about individual patients have been pushed from center stage. Their place at the table has been eclipsed by hospitals, medical centers, chains of hospitals and clinics, and finally insurance networks. These mega-providers are seeking more control of individual medical decision-making daily to increase standardization in the name of assuring quality, reducing cost and increasing revenue.

This setting, by its very nature, requires a variety of new organizational forms for disenfranchised practicing physicians. Physicians attempting to provide personal, compassionate care to individuals within mega-provider institutions are all too often subjected to pressures to increase the numbers of patients seen and reduce the time per patient. Often these pressures are modulated by the personality of the current CEO or department chief.

The emotional and economic separation of these health care administrators from the direct provision of care to individual patients creates a clear differential in interest with their clinicians and patients. Clearly, there is a role here for an organization of practicing physicians primarily concerned with issues of practice control to assure quality care for patients in an environment supportive of clinicians. Unquestionably this is a situation in which a contract that defines limits and responsibilities for institutional decision-makers and a place at the table for practitioners is advantageous.

In many mega-practice settings, this collective contract is negotiated by the medical group with the institution's owners. In other settings of employed physicians, a union collective bargaining agreement serves this purpose. The additional value for practitioners for this latter mode is that it often places the doctors in coalition with the array of health care professionals represented by unions. This permits a broader patient/professional advocacy from within an organization representing both.

Last month, in these pages, Drs. Cassel and Brennan concluded a piece on the environment of medical practice by saying, "Allocation decisions will be made but without regard for the caring, commitment, clinical expertise and wisdom of experience that clinicians bring. Given this, physicians must make a professional decision about the correct approach and advocate for change both individually and collectively."

Union organization and collective bargaining deserve a respected place among the ethical options available to physicians today to accomplish these professional and societal goals.

Peter Orris, MD, MPH, immediate past president of the medical staff, Stroger Hospital of Cook County (Ill.); professor of internal and preventive medicine, Rush Medical College; member, Organizing Committee, Doctors Council, Service Employees International Union Local 20

Reply:

In response to budget cuts resulting in the elimination of dozens of physician jobs, physicians employed at a Cook County (Chicago) healthcare institution are forming a union. Unionization's goals are to ensure doctor involvement in future budget and management decisions and to improve the quality of and access to care. In our market-oriented and cost-preoccupied health care environment, unionization may be perceived by frustrated physicians as the only means to achieve these goals. While the short- and long-term effects of unionization in the Chicago situation remain to be seen, physician unionization in general is unnecessary and potentially harmful.

The focus of a physician union is on the employee physician. Unions try to extract benefits for members through collective bargaining with employers. For the doctor, however, joining a union creates a serious conflict: the union physician has obligations not only to patients, but also to the union and fellow union members. This conflict, in turn, may erode trust patients must have in physicians.

Patients are vulnerable due to a variety of factors -- for example, illness and lack of knowledge. Physicians frequently are the only ones capable of acting on patients' behalf -- for example when dealing with insurers. The public must trust that physicians will put the interests of patients before their own. While union physicians may sincerely desire to improve the quality of and access to care, the mere perception that physicians have interests that interfere with their obligations to patients may threaten the trust on which the patient-physician relationship depends.

Physician unionization may have other unintended effects. Suppose, for example, nonphysician members of a union to which physicians belong elect to strike. Would the physicians be required to honor picket lines? What if the union demands concessions from employers that are, in fact, detrimental to patient care? Indeed, the AMA's Code of Medical Ethics states that "formal unionization of physicians ... may tie physicians' obligations to the interests of workers who may not share physicians' primary and overriding commitment to patients. Physicians should not form workplace alliances with those who do not share these ethical priorities."

Physician unionization also may adversely affect the profession's privilege of self-regulation. The Physician Charter developed by American Board of Internal Medicine Foundation and other professional groups says, "As members of a profession, physicians are expected to ... participate in the process of self-regulation, including remediation and discipline of members who have failed to meet professional standards." Suppose that, based on formal review, a union physician is found to be unprofessional (and thereby potentially harmful to patients), necessitating discipline by or even expulsion from a medical staff? Would the union respect this self-regulatory process, or would the union interfere with it and intervene on behalf of the physician? Finally, collective actions by physicians that disrupt patient care may have antitrust implications.

But what should physicians do if they are faced with unacceptable conditions that compromise patient care?

First, they should reaffirm professionalism and their commitments to patients, rather than resort to unionization. A core principle of professionalism is primacy of patient welfare. For example, physicians will put the interests of patients before their own. In reaffirming professionalism, physicians should partner with patients, business leaders, policymakers, the media and others in publicizing conditions that compromise patient care.

Second, more physicians should become leaders in their institutions, join health care-related government committees and regulatory boards, and so on. The efforts of these groups should not be delegated to nonphysician businesspersons, lawyers, politicians and others who may not share the professional values of physicians.

Third, physician threats to unionize often reflect poor management. Hence, physicians should insist that the "business" aspects of their work be managed properly, rather than passively allowing poor management to result in staff reductions and inadequate patient care.

Fourth, physicians should avoid working for organizations that reward productivity at the expense of quality, access to care and patient satisfaction. Fifth, medical educators at all levels should emphasize professionalism and its principles.

Finally, specialty societies and other physician groups should work together to advocate vigorously on behalf of patients. As Jordan J. Cohen, MD, president emeritus of the Assn. of American Medical Colleges, writes, "We need to be united, but we do not need a union."

Paul S. Mueller, MD, MPH, associate professor of medicine, Mayo Clinic College of Medicine; member of the American College of Physicians' Ethics, Professionalism, and Human Rights Committee

Note: In 1999, the AMA passed its landmark policy on physician unions. It states that all AMA activities regarding negotiation by physicians maintain the highest level of professionalism, consistent with the Principles of Medical Ethics and the current opinions of the Council on Ethical and Judicial Affairs. Other items included in the policy are that the AMA continue to support the development of independent housestaff organizations for resident and fellow physicians and that the AMA continue vigorously to support antitrust relief for physicians and medical groups by actively supporting federal legislation and continue providing model legislation and information on the state-action doctrine to state medical associations and members.