How Physicians Can Unionize and Strike With Compassion

A few weeks ago, the longshoremen’s union shut down 14 ports along the East and Gulf Coasts. This strike of dockworkers was costing the American economy up to $5 billion per day. The strike lasted 3 days, and there was an agreement to suspend the strike and continue negotiations in early 2025.

One of the primary issues pertained to restricting the use of automation and artificial intelligence to load and unload freight. The longshoremen’s union was demanding a provision in their contract prohibiting the use of automated gates, cranes, and container-moving trucks to load and unload cargo. Clearly, longshoremen do not want artificial intelligence to replace their jobs.

In the case of the dock strikes, much of the panic stemmed from the possible economic tsunami. But in healthcare, the calculus is slightly different. Can you imagine if doctors were to go on strike for 3 days? The impact on patient safety could be catastrophic, even lethal in some cases.

A labor strike is the nuclear weapon of unions, the best tool against egregious workplace abuses. Without that tool, doctors would have far less negotiating muscle. At the same time, the reluctance of doctors to gravely imperil patients by striking is perfectly justifiable.

Fortunately, there may be an attractive third alternative to the polarized choice of either unionized physicians striking or declining to unionize at all. I have given a name to this alternative: compassionate strikes.

First, we should acknowledge that it may be easier to herd cats than independent-minded healthcare workers! But times are changing fast, with burnout among healthcare workers reaching epidemic levels.

A main concern is the long work hours that begin in medical school and training and continue in practice. The average workload for a medical or surgical resident exceeds 80 hours a week, and a practicing physician works 10 hours per week more than the average American worker.

In addition to this traditional stress, doctors are unhappy due to a growing lack of purpose and meaning in their work and personal lives. Physicians say they are burned out mainly because of too many bureaucratic tasks. Physicians today spend as much as 2 hours daily entering data into the computer to meet hospital and insurance company requirements. This is often uncompensated time, and doctors are resisting being data entry technicians; they prefer to focus on the patient and not the computer.

All this can cause even the most resilient physicians to lose sight of why they became doctors — and to consider joining a union. Moreover, independent physicians have limited clout to negotiate with hospitals and insurance companies. Unless physicians are in a unique geography or have skills in high demand, they are likely to hear “Take it or leave it” in contracting and negotiating.

In contrast, doctors who have joined unions have a unified voice to advocate for improved working conditions, which includes limiting working hours. Union membership can also provide access to legal counsel and current information on regulatory issues. This helps protect physicians from lawsuits.

We have known for a long time that overworked physicians make more errors, thus impacting patient outcomes and increasing the risk of litigation. Union representation not only benefits physicians’ well-being but also enhances patient care, which is every physician’s first priority.

Now, let’s look at the flip side of the union coin. Union membership usually results in a loss of physician autonomy. Unions function as a democracy, and they typically make decisions based on the majority vote. Physicians who disagree with the majority may end up feeling underrepresented or neglected.

Union membership also requires membership fees, which can be significant for certain physicians already burdened with student loans and other financial obligations.

Going back to the longshoremen’s strike: if it had lasted longer, massive goods shortages might have crippled the national economy or even sparked a recession. However, the longshoremen’s strike did not endanger the lives of others.

Enter the compassionate strike. First, to head off a public relations crisis for the healing profession, unionized physicians should set ethical ground rules for strikes to ensure patient safety. The National Labor Relations Act stipulates that physician unions must give employers a 10-day notice of a refusal to work.

Second, compassionately striking physicians must also ensure that emergency care is available and that hospitalized patients continue to receive care.

Third, in prolonged strikes, they must regularly evaluate the collective effect of their behavior on patient care. Every effort must ensure no gaps in care during a strike.

Fourth, and perhaps most importantly, doctors have considerable power of the purse. Their employers’ revenues are almost totally dependent on data the providers enter into electronic medical records. Without convenient and efficient access to that data, billing and revenues would slow to a crawl. Therefore, compassionately striking doctors could continue caring for patients as they normally would but simply revert to paper charts, just like the days before the electronic medical record. Imagine the billing department’s time and expense of deriving data from paper. I’d believe any strike would be over in days.

In addition, a physician’s union could thwart employers’ demands that employees use electronic health records exclusively. That’s one example of the power of collective bargaining.

Bottom line: Physicians must carefully weigh the pros and cons before deciding whether unionization is the best choice for their professional careers. However, unionization can be achieved ethically if the focus is on improving patient care, not physicians’ self-interest.

Neil Baum, MD, is a urologist in New Orleans, the corporate medical officer of Vanguard Communications, adjunct professor at the Tulane University School of Medicine in New Orleans, and the author of The Complete Business Guide for a Successful Medical Practice.

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