Even just 20 years ago or so, the idea of physician unionization would be met with derision at worst and skepticism at best. However, with the sharp increase in employed physicians over the past few decades, the concept and debate of whether doctors should, or even can, unionize has taken off. In fact, just the other day in the surgeon’s lounge, another surgeon brought up the idea to me. Moreover, the residents at the medical school that I work with recently unionized and completed a strike. So this idea hits close to home.

It’s a topic that is sure to elicit strong opinions. I’m not going to necessarily hop on one side of the fence or the other. There was a time when I would have, to be honest. But the discussion is a bit more nuanced once you take some of the emotion and “we just need to keep doing what has always been done” attitude out of it.

I’m going to try in this post to present a fair discussion of both sides of the argument. I encourage you to think about this with an open mind as well. And then of course, let me know what you think after!

Is physician unionization allowed?

Let’s get this out of the way first. Because it is a legitimate question.

Yes, doctors can form unions. In fact, some physician unions already exist. The Union of American Physicians and Dentists was founded in 1972. And the Council on Interns and Residents represents 30,000 members throughout the country. In fact, when I was trining at NYU, my employment was technically with Bellevue Hospital for many years and I was a part of this union.

So, physician unionization is allowed.

However, it has largely been without teeth for a variety of reasons. First, there has been pretty limited interest in the idea of forming a union let alone employing some of the strategies that unions use from doctors themselves. Even those in the unions.

Second, these unions are very broad. They contain doctors, dentists, trainees, etc. Without a more narrow focus, it’s hard to really represent anyone’s interests.

Thirdly, only employed physicians can unionize. So independent physicians are on the outside of these efforts.

And lastly, there are antitrust laws that would potentially come into play if unions interfered with competition in the healthcare space.

So, while technically allowed, these issues have prevented doctor unions from really taking off or making any noise in the healthcare system.

Until recently.

So what changed?

The biggest factor is probably that more and more physicians now are employed.

But there are other issues at work as well. During the COVID-19 pandemic, doctors saw firsthand just how “replaceable” we are or are perceived to be by the healthcare system. Additionally, burnout reached new heights since that time.

The culmination of these and other more local factors is that doctors began to worry about their place in the healthcare system. We gave up lots of control and all of sudden were acutely feeling the effects of this shift.

As a result, physicians sought more control.

One manner of achieving more control, for the increasing proportion of employed physicians, is unionization.

And here we are. So, the question becomes, are physicians’ unions good or bad? Like anything, the answer is a shade of grey.

The pros and cons of physician unionization

Let’s look at some of the biggest pros and cons of physician unionization…

The pros

Better leverage in contract and workplace negotiations

Individual doctors working within a large healthcare system feel like cogs within a wheel. There is significant concern that their voices are not and will not be heard. Unions offer the potential of aligning individual voices into a much large one that has to be heard and listened to by the healthcare system. In theory, this leads to better pay and working conditions.

Improved doctor well-being

More leverage leads to more favorable outcomes in negotiations for doctors. And better compensation and working conditions leads to happier doctors. Happier doctors have less burnout.

Better patient care

See above. Subsequently, less burnout equals better patient care. Further, happier doctors would practice longer, reducing the severe shortage in this country.

More autonomy for and protection of the professional standards of physicians

A huge concern for physicians is again the loss of control of the practice of medicine as the healthcare model shifts more towards an employment model. Unionization theoretically would protect the professional standards of doctors from any administrations more focused on business issues.

And now for the cons…

The cons

Increased healthcare costs

This is the main reason that healthcare systems cite. Unions and collective bargaining will increase costs, mainly related to improved working conditions and physician compensation. This, in turn, reflects in the cost of healthcare which rises even more for the average American.

I’m sorry but I don’t buy this one. Administrative costs and the number of healthcare administrators has risen exponentially compared to other healthcare related costs in the US. Fair working conditions along with improved and fair compensation for doctors should not be at the expense of these more significant costs. Especially given that improved doctor well-being translates into improved patient outcomes.

In fact, one could argue that unions, by increasing physician satisfaction and longevity, would decrease costs by reducing physician turnover and its huge associated cost.

Strained relationships among doctors

This may sound wishy-washy or woo-woo. But this is probably the biggest con in my head.

Because, no matter how specific and small, any union represents a broad and diverse set of priorities that differ among their members. Within medicine, there are various specialties, levels of training, experience and more that factor into one’s professional and personal priorities. No union will ever appropriately represent all of these.

Further, not all doctors within a system may agree with unionization.

Both of these situations can cause resentment and dysfunction within a working environment that requires collaboration and collegiality to best help patients.

Reduced administrative efficiency

This is a kind way of saying that it is very hard to discipline or fire a union worker. When that union worker is a physician practicing dangerous, impaired, or ineffective medicine, it could create a real problem for patient care.

The fall of the independent practitioner

Let’s say physician unions become a thing and are very successful at negotiating, namely, better working conditions and compensation for doctors. Let’s say they do such a good job that it no longer makes sense to practice independently or in private practice.

Would this be good or bad?

I guess in this hypothetical world where physician unions were so successful that it could be good. But overall, I think this would be a negative development and ultimately result in more lost control for physicians.

Worse access to care for patients

Another argument against physician unions is that better working conditions including better staffing, reduced hours, etc would result in less access to care for patients. I don’t buy this either as the argument that the only way for patients to get care is to burn doctors out is a non-starter for me. Further, improved conditions lengthening doctors’ careers would offset this.

The other part of this argument is that a strike would significantly and unfairly impact patients and their care. This is a sticky one. Obviously a strike would be a worst case scenario. And it need not be long lasting. Some even promote the idea of 15 minute strikes or a strike on documentation of medically unnecessary exams etc. that are pushed for maximum system compensation with little tricks down to the physicians doing the documenting.

Misaligned patient-physician priorities

Unions could theoretically put physicians needs and priorities above those of the patients. This could result is a misalignment of interests that hurts patient care. I think this is a bit of stretch and plays into the old and false taboo that doctors shouldn’t think about money. As doctors, we have an oath to patients that I don’t think (maybe naively) this would impact.

Bad public optics

This is maybe the biggest concern of most doctors. It’s certainly possible that patients or the public view unionized physicians as less professional or breaking an oath to their patients if they strike. After all, doctors make a lot of money. The public don’t necessarily buy the idea that doctors can be burned out or aren’t being paid fairly…despite that being the objective case.

What’s the verdict?

There are certainly more ticks in the “con” column than in the “pro” column. I don’t think that means that physician unionization is bad necessarily.

To be honest, I don’t know where I stand. I certainly understand why physicians want to unionize. And I can see where short term advantages would lay in this approach. I do have long term concerns however, mainly that it would involve giving up more control to non-physicians – union leaders in this case. Of course this is assuming no physicians lead unions. But I am skeptical we would.

I do know that, at this moment, I stand in a privileged position in this debate. I am employed. But I negotiated a favorable contract and have an excellent clinical situation. So I don’t (at least currently) “feel the squeeze” leading many to favor doctor unions. I can imagine myself in that situation all I want, but can’t say for sure how I would feel in those circumstances.

I want to know where you fall on this topic however.

But first, there are thankfully still things that we all as physicians can do, no matter the practice setting, to improve our professional and personal well-being, compensation, and work setting. Here are some resources to help:

• Exploring an Exciting New Employment Option for Doctors
• 9 Things You Must Know About Starting a Private Practice
• 3 Biggest Reasons for the Massive Intra-Specialty Pay Gap in Medicine
• How to Negotiate Your Physician Contract
• 7 Do’s and Don’ts of Building a Successful Practice

What do you think? Should physician unionize? Why or why not? What are the short or long term implications of physician unionization? Let me know in the comments below!