Image by Getty Images
Image by Getty Images
Business of Medicine | September 21, 2022 | FREE
Most ACP Hospitalist content is available exclusively to ACP Members. This article is free to the public.

Why are physicians unionizing?

Residents recently voted to newly unionize at Stanford University, the University of Southern California, and the University of Vermont, among other programs.

From your neighborhood Starbucks to local residency programs, it may seem like everyone is forming a union lately.

Although only 6% of Americans currently belong to a union, the number of votes that groups of employees cast in favor of unionizing rose dramatically from the first half of 2021 to 2022, according to a Bloomberg Law analysis. Public opinion of labor unions has risen as well: 71% percent of Americans approved of them in an August Gallup poll, up from 48% in 2009.

In hospital medicine, residents recently voted to newly unionize at Stanford University, the University of Southern California, and the University of Vermont, among other programs.

Union membership is surging among residents, according to ACP Resident/Fellow Member Yariana Rodríguez-Ortiz, MD, executive national vice president of the Committee of Interns and Residents (CIR), a nationwide organization affiliated with the Service Employees International Union. “We were only a union of around 14,000 members in 2017. And as of today, we have 22,000 members inscribed,” she said.

Unions are rarer among internists who have finished training, but there's also at least one unionized hospitalist service in the U.S. To learn what's motivating the current interest in unions among physicians, ACP Hospitalist recently spoke to internists who have participated in or studied the phenomenon.

Motivating the trend

As with almost every recent societal change, one likely contributor is COVID-19.

“The pandemic has pushed us to question what management's telling us to do, and we're finding we have very few tools and resources to make our point of view known,” said Kevin Schulman, MD, a professor of medicine at Stanford and an author of a Viewpoint on unions, published by JAMA on July 28.

At the University of California, Los Angeles (UCLA), residents already had a union before the pandemic, but it's provided them new benefits to compensate for the intensified challenges of their jobs, explained ACP Resident/Fellow Member Dayna Isaacs, MD, a UCLA resident and regional vice president for CIR.

“We gave residents at hospitals with very limited food options Uber Eats benefits, since finding time to meal prep during residency can be very hard,” she said. The residents are also now spared peak charges on ride shares “when we feel that it is unsafe to drive due to fatigue from our long hours,” Dr. Isaacs said.

However, like long shifts, some of the drivers of unionization started long before COVID-19, according to Dr. Schulman. “The change in organizational structure has been really dramatic over the last decade,” he said. “We [physicians] have never been employees at the scale that we're employees now.” As recently as 2012, only about 6% of U.S. physicians were employed by hospitals, and now about three-quarters work for a hospital, health system, or other corporate entity, he noted.

Those employers have also become much larger entities, Dr. Schulman added. “What 30 years ago was a stand-alone hospital, even a stand-alone academic medical center, now is part of a big integrated system, and the goals and the mission may not be clear.”

Aligning employers' policies with physicians' goals is one motivation to unionize, Dr. Schulman said, offering an example: “If we want our hospital to offer pediatric psychiatric services, because our children are suffering and their friends are suffering, but the corporate office in some remote city doesn't prioritize that, how can we have a collective response to their decision?”

Another factor is that as their employers have been evolving, physicians, especially younger ones, have been changing their perspectives on work.

“There's been a shift in the modern perception of what it means to be a resident. That includes a larger focus on life outside the hospital, including starting a family, continuing hobbies, spending time with friends and family,” said Dr. Isaacs. “It is possible for residents to have lives outside of medicine.”

Duty-hour restrictions from the Accreditation Council for Graduate Medical Education (ACGME) planted the seeds for this effort, said Dr. Rodríguez-Ortiz, who is also a nephrology fellow at Houston Methodist Hospital. “It wasn't until after ACGME started fighting for resident well-being that this idea that ‘Hey, doctors also have rights, they're also human beings' started to be brought up.”

In addition to a life, residents also increasingly want a voice, added ACP Member Pooja Jaeel, MD, a recent graduate of the unionized medicine/pediatrics residency program at the University of California, San Diego.

“It seems like there's a lot of stuff that happens to us and is decided for us, and having some thought leadership … and some legal representation gave us some sense of having a little bit more power in that dynamic,” she said. For example, she said the union's legal experts helped her better understand her program's sick leave policy.

Residents may be motivated to unionize by all these factors and others, and the impetus often differs from one program to another. Some organizing may be driven by issues with working conditions, while other times residents are particularly focused on the quality of patient care, according to Dr. Rodríguez-Ortiz.

Efforts by resident unions to improve conditions for patients have included getting hospitals to increase nurse staffing and acquire ultrasound machines, Dr. Rodríguez-Ortiz said. Union concerns like these are often shared by attending hospitalists. Tenure and tenure-track faculty can't unionize because they are considered managers under the law, but they can cooperate with resident unions to accomplish mutual goals, she noted.

“We can actually work hand in hand not only to improve working conditions, but to help our patients. At the end of the day, we are all working for a common good,” said Dr. Rodríguez-Ortiz. “I want to break that stigma of people thinking forming a union is actually a bad thing.”

A union for hospitalists

Some nonacademic hospitalists, including ACP Member Marc Zarraga, MD, have already decided that unions are a good thing.

Dr. Zarraga serves as vice president of the Pacific Northwest Hospital Medicine Association, which represents hospitalists at Sacred Heart Medical Center in Springfield, Ore., and became the first hospitalist union in the country in 2015. He joined the group shortly after the union was formed.

“I think forming the union has really helped us grow the program,” Dr. Zarraga said. “Once you have these things in place, each hospitalist has a good work-life balance.”

Before the union, hospitalists were employed by the hospital under individual contracts. In 2014, the health system proposed to take bids from outside companies to provide hospitalist services. That motivated the formation of the union, which was a novel concept coming from employed physicians, although the hospital already had unionized workers of other types, such as nurses.

The hospitalist union then underwent lengthy negotiations with the health system about many issues, including workload, schedule, and pay, and eventually both parties agreed to a contract. The most recent contract was negotiated a year ago and runs through October 2024. Belonging to the union is a condition of employment for hospitalists at the facility, so new hires immediately become members of the union, explained Dr. Zarraga.

The collective contracts cover not just pay, benefits, work hours, and staffing, but also tasks such as committee participation, among other issues. The union has also targeted specific concerns of its members, such as streamlining of workflows and comanagement agreements with subspecialists, according to Dr. Zarraga.

“The main benefit for us is basically a good working relationship between the hospitalist group [and] the administration. … Basically, we have a seat at the table with decisions that need to be made,” he said.

Because hospitalist unions are such a rarity, physicians interviewing for a job with the program often have a lot of questions, Dr. Zarraga noted. “A lot of them, like me, did not really know how a union works,” he said.

That's not surprising, according to Dr. Schulman. “Physicians, obviously, are not well educated in this space about the laws and what our rights are and what are our opportunities are, and so there's a bit of learning that has to go on,” he said. “We really have to take a step back and think about the challenges we face individually as collective challenges and governance challenges.”

The results of that analysis will likely show unionizing to be the best choice for some hospital physicians, but not all, others agreed. “It really depends on the environment of their program and their relationship with the administration,” said Dr. Zarraga. “I think it's case by case.”