Dressed in hospital-issue, starched uniforms emblazoned with the New York City Department of Hospitals logo, we sat across a table from a team of the city's fiscal administrators and argued for a $10,000 salary for interns at public hospitals. I wore a flowered tie, smoked a pipe and talked ominously of "fed-up residents who weren't going to take it anymore from the city." The year was 1971, and I was leading a team of doctor-negotiators from New York's Committee of Interns and Residents (CIR). I was a resident. We were a doctors union, and I was its president.
But there was a wrinkle. Our team was made up of activists determined to make the CIR an instrument of patient-care improvement in the city's generally second-rate and largely ignored public hospitals. Our demands were not limited to pay and benefits. We put an unorthodox package on the bargaining table that also included more nurses for short-handed wards, 24-hour laboratory staffing, and enough orderlies to move patients and specimens around the hospital.
Our bold strategy caught the city by surprise. How could doctors be negotiating for nurses in the doctors' contract? What would happen to management's authority if the residents could dictate hospital staffing patterns? Eventually, the city agreed to some minor concessions on staffing but craftily split our ranks by offering generous salary increases in return for dropping the patient-care demands. When push came to shove, the average resident working an 80-hour week and trying to get home for supper occasionally was quite happy to take the pay increase and call it square.
Although our venture into patient-oriented collective bargaining did not produce a health-care revolution, it was by no means the last pass at the public-spirited unionization of doctors. Today, CIR represents 9,000 of the approximately 40,000 unionized physicians nationwide, and is an affiliate of an AFL-CIO union. Since that early battle, my profession has changed in ways I couldn't have imagined. Then as now, however, the frustrations of practicing in a hospital that lacks the people or resources to give good care has made radicals out of more than a few conservatives.
Now the American Medical Association (AMA), of which I am a member, is preparing to travel the same path. It voted last month to form a national negotiating organization whose purpose, according to AMA president-elect Randolph Smoak Jr., is to give doctors "the leverage they now lack to guarantee that patient care is not compromised or neglected for the sake of profits." In other words, they are going to form a doctors union and they will want me to join. I find a modification of the old trade union song running through my head: "Which side am I on, which side am I on?"
This time, I am not finding it as easy to pick a side.
Life has changed dramatically for American physicians in the past decade. The number of salaried physicians is way up, while those in independent practice struggle with the tangled guidelines of competing third-party payers. Managed-care organizations make decisions that we used to make. Insurance carriers that once upon a time happily paid the bills now dictate what procedures we can and cannot do. Some of the standardization and limits that managed care has brought to health care are beneficial and overdue, but the proliferation of plans, forms, rules and monitors that are visited on us daily are flat-out infuriating. Beyond that, doctors are under constant pressure to see more patients, limiting the important time we have to spend with each one. Many doctors perceive they are impotent in the face of managed care and insurance companies, and believe collective bargaining can restore more say about their professional futures. Some doctors are worried about their incomes, but the most universal complaint I hear is about the complexity, intrusiveness and weight of the system that has engulfed the practice of medicine.
Under current antitrust laws, only salaried doctors can unionize. Still, unionization appeals because it would provide those doctors with a means of battling back against the business-driven forces that are loose in medicine. No one is in a better position than medical professionals to point out where the system is being stretched thin, where health plans are stinting on patient care or where people lack care altogether.
Physicians are ideally placed to serve as monitors and watchdogs of the commercial forces that determine so many clinical decisions these days. And collective bargaining would provide a political megaphone to trumpet these issues to the executives of managed care and insurance companies, to the public and to politicians. Although today's managed-care confrontations are vastly different from my city hospital battles of nearly 30 years ago, the doctors union idea still appeals to me as an effective way to address grievances and improve patient care.
Yet the idea of a doctors union also conjures up images of greed and selfishness. We may be frustrated as a profession but we are hardly disenfranchised. Our incomes average a bit more than $160,000 a year. Pay and benefits are traditionally at the core of what unions negotiate, and the specter of well-paid doctors banding together to protect their presumed Lexus entitlement is not pretty. The notion of doctors walking away from patients or hospitals as part of a dispute over retirement benefits or on-call schedules seems outrageous. Whatever the intentions of the current AMA leadership, the possibility of doctors unions as a vehicle to help the rich get richer is real--and ugly.
The question, at bottom, is whether we as physicians can serve as public advocates without using that position as a platform for simple self-interest--some groups demanding more patients, others trying to legislate procedures and everybody whining about income. That question seems as vital and as tricky to me today as it did when I sat at the New York bargaining table in my starchy whites.
Stirred by the memories of that earlier experience but chastened by its outcome, I am going to wait and see what shape the AMA's union takes. My guess is, though, that many of my colleagues will soon join in the belief that it is the only way for them to have a say in the system. Whether this union ends up looking more like a medical Common Cause or a professional protection racket will be up to doctors themselves. Leaders who are committed to the use of the collective power of doctors to improve patient care will be essential. But their best and most public-spirited efforts will fail and the AMA union will degenerate into a doctor-welfare program if the majority of doctors--medicine's rank and file--don't line up behind these same patient-care goals. New York City's labor negotiators of the '70s weren't the only people who could figure out how to "play to the lunch pail," offering popular but diversionary concessions that will split a principled movement apart.
Fitzhugh Mullan is a staff physician at the Upper Cardozo Community Health Center and contributing editor of Health Affairs, a journal published by Project Hope in Bethesda.