By Karel-Bart Celie.
In a recent issue of JAMA, Ahmed et al. published data on healthcare unionization in the United States between 2009 and 2021. Despite the observed association between unionization and higher wages, better benefits, and more equitable compensation, unionization among healthcare workers has evidently remained low. Richman and Schulman (R&S) wrote a commentary focused specifically on unionization by physicians. They argued that physician unionization helps (1) restore some governance of healthcare systems and (2) provide a mechanism by which to deploy professional ethics in the service of patient welfare.
To the first point, more than half of all U.S. physicians are now employed by hospitals or other health systems. This shift in the landscape has resulted in a decrease in “professional sovereignty” threatening the loss of professional independence—something unionization might help prevent. Regarding the second point, leaders of large health systems have at best a divided loyalty; they are obligated to prioritize the fiscal concerns of their institutions. For example, one way to maximize profits is to minimize staffing despite a burned-out workforce and evidence that such practices can lead to worse outcomes. Physicians, on the other hand, have less of a commitment to the financial bottom line of the institution. And in any case, deeply-ingrained professional ethics serve as a corrective that “counters market incentives.” Unionization provides physicians with a “means to exert influence” on large health systems, in a manner that reflects the profession’s dedication to patient welfare.
I agree with these points and would like to submit two additional observations.
First, the age-old call to “at least do no harm” cited by R&S, which appears in Book I of the Epidemics, is often interpreted in relation to patient care. However, there is also a contextual argument for a similar duty to colleagues in the Hippocratic corpus. The Hippocratic Oath devotes a sizeable second paragraph to describing the respect and care with which one should treat one’s teachers and pupils. This paragraph accounts for nearly a third of the total text, and exhorts its reader to regard both teachers and pupils as family. It serves to remind us that our duties are not only to patients, but to each other as well. This is an aspect that is under-emphasized, to the detriment of a profession that is so inexorably collegial. How we consult with physicians from other specialties, with nurses and other allied staff, and with those who are learning from and teaching us, all have an impact on “the profession” and how its values are applied. The doctor-patient relationship—recipient of much attention—exists only in the context of physicians who constantly learn from, teach, and interact with each other.
The communal aspect of our professional ethics is obliquely understood, for example, when reporting unprofessional conduct. However, we do not have to stop at the negative. Physicians are accountable to each other in a positive sense also. Unionization is one way of giving this positive, intra-professional obligation a voice. It does so by promoting an environment of mutual support, collegiality, and legitimate concern for the wellbeing of members of the profession.
Second, housestaff unionization merits special attention at a time when burnout and depression remain prevalent among trainees in medicine. Unions help ensure fair wages and benefits; at my institution, wages for first-year doctors have risen by 15% since 2020. The accrediting body for graduate medical education (the ACGME) in the U.S. has increased initiatives to improve wellness in graduate medical education since 2017. However, it wields its punitive power over residency programs which are often themselves under pressure of the demands put upon it by institutions. Residents and their teaching faculty are often together in the proverbial “trenches.” Complaints to the ACGME are therefore challenging and often last-resort options for help, since everyone knows that doing so may simply shift the burden to another demographic (e.g., by removing trainees from a rotation, the same patient volume falls on the remaining faculty). Take for example the rule—a definite step in the right direction—that trainees are to work no more than 80 hours per week (caveat: averaged over 4 weeks!). Environments with low levels of staffing and high patient volumes virtually guarantee unacceptably high housestaff work hours. How could it not, especially where patient care is prioritized? Unions by contrast are more capable of addressing root causes, such as low levels of staffing, by directly confronting institutional stakeholders without necessarily compromising patient care. They also have the potential to spur legislation which holds institutions accountable for the treatment of their staff.
It is also important to note that housestaff unions can have a direct impact on improved patient care. The Patient Care Fund (PCF) was established by the Committee for Interns and Residents (CIR) in Los Angeles County in 1975 as a funding mechanism for trainee-driven improvements in patient care equipment. Since then, similar funds have been established by CIR across the country. In the last three years, housestaff from my own division have acquired a combined pulsed dye laser (PDL) and neodymium yttrium aluminum garnet (Nd:YAG) laser for burn reconstruction, as well as a new microscope for free flap reconstruction and digital replantation. All together this equipment represents nearly $300,000 invested in patient care at one of the busiest county hospitals in the country.
In summary, unionization by physicians in the U.S. provides a mechanism for us to apply our professional ethics, and thereby honor our (underemphasized) duties to each other. As a surgical trainee, I have also found that unions hold the potential to provide a more direct path to housestaff wellness than those currently afforded by educational organizations. For these reasons physician unionization merits continued support, despite the low rates reported by Ahmed et al.
Author: Karel-Bart Celie
Affiliations:
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Operation Smile Incorporated, Virginia Beach, VA, USA
Competing Interests: None declared
Social media accounts of post author: Instagram @celie.md