* Darlene Lawrence is a family physician serving Southeast and Northeast Washington:

I support the AMA proposal but feel that the AMA has not gone far enough in saying that it will form collective bargaining units for America's physicians. You see, the AMA, of which I am a member, has said it would not strike in the case of failed negotiations. Without the threat of striking, the collective bargaining unit or "union" has no real strength--we have no ammunition. I feel that the AMA has made the right decision in supporting the Campbell bill [Quality Health Care Coalition Act] in the House, which would create an exemption in federal antitrust laws, allowing physicians to bargain collectively with health insurers. But the AMA should do even more for its hundreds of thousands of physician members by helping to introduce a Senate version of the bill to change the century-old antitrust laws.

* Alan S. Chanales is a pulmonologist in Rockville.

I favor some kind of union-like organization for physicians to restore some balance to the relationship between doctors and health insurance companies, which currently is lopsided in favor of the companies. Terms for a whole range of issues--both business- and patient-care-related--are now dictated by the insurance companies on a take-it-or-leave-it basis.

We physicians are losing our sense of professional independence and status. We are losing the bond of loyalty with our patients and with our referring physicians. And we are losing the economic rewards that we expected to get for our long years and unbelievable hours of training--years that delayed our earning power until we were in our thirties. Do you not already see the erosion of quality of service taking place? It is time to restore some balance, and a union is the only effective tool I see on the horizon.

* Jerome P. Kassirer, an internist and nephrologist, is editor in chief of the New England Journal of Medicine:

The decision by the AMA to form collective bargaining units is a sad turn of events.

Despite the AMA's assertions, unionization is not an effective tool to improve the quality of patient care or to deal with intrusions on doctors' decisions, excessive patient loads and burdensome paperwork. In fact, existing unions have had little success in helping physicians solve disputes with hospitals and health plans.

Collective bargaining is well-suited to negotiations about money and working conditions, but this is not a great time to negotiate for more money. Expanded drug benefits, possible reinstatement of cuts in Medicare spending and possible expanded benefits through a Patients' Bill of Rights will contribute to accelerating costs of medical care. And in the final analysis, a union has virtually no clout without its big stick--the strike--and this tactic the AMA has properly renounced.

But my chief concern is that unionizing will degrade the perception of medicine as a learned profession governed by high ethical standards. Because collective bargaining inevitably focuses on income, the self-interest of physicians--not patient care--could be seen as the profession's dominant focus.

Given doctors' prolonged training and the long, arduous hours that they work, doctors deserve to be paid well. But making money must not be the fundamental goal of a physician, and a financial yardstick must not be the principal measure of our profession's success.

* Lanny Copeland is a family physician in Albany, Ga., and the president of American Academy of Family Physicians. The views expressed here are his own.

While I have no opposition to physicians joining unions, I worry about the rationale of the AMA developing its own collective bargaining units. The current legal system would only allow physicians who are employees and physicians in training to be a part of this new entity, which translates to only 1 in 7 of the U.S. physician work force.

The bigger issue is finding a way to balance the disparity between what physicians believe their patients need and what payers are willing to pay. Just what role should a professional membership organization, such as the AMA, play? The AMA will now be encumbered with the cost and energy to carry out the task of establishing unions. This will be no small feat--and would potentially benefit only 15 percent of physicians. Perhaps we could at least have deferred this decision until we see whether the Campbell bill is passed.

I don't believe the union is the answer to relieve the frustration experienced by so many in our profession as we try to better advocate for our patients.

* Jay Crosson, a pediatrician, is executive director of the Permanente Federation, the umbrella organization for Kaiser Permanente's 11 medical groups and 10,000 physicians.

I view the AMA's decision from the perspective of a physician who has had the good fortune of spending my entire career in what I believe is a better vehicle than labor unions for ensuring that health care stays firmly in the hands of doctors and their patients--a large, physician-owned and self-governed medical group.

If physicians are to reclaim the prerogatives of autonomy and leadership in health care (not to mention enhanced income, which the AMA carefully does not mention), they must do so in a way that best facilitates the delicate balancing of self-interest with the interests of their patients. As much as I respect the strength and creativity of organized labor, I doubt that a labor union is the best vehicle for carrying this out. Instead, physicians have at their disposal an alternative: that physician-owned and self-governed medical group, which functions much like a labor union in collective bargaining for HMO contracts.

California, where managed care first became a significant force, provides a powerful example. There, large medical groups, independent practice associations and integrated physician-hospital organizations now provide what amounts to collective bargaining for the majority of physicians in the state.