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In a landmark move, the Chicago-based American Medical Association (AMA) has proposed forming a unionlike organization for employed physicians.
The AMA is creating a board of directors for the negotiating organization, reports Mark Bair, MD, FACEP, chair-elect of the AMA Young Physicians Section, also based in Chicago. After the board is created, the organization will begin taking form.
"In emergency medicine, there are a lot of employed physicians, so there is a definite market for a union. Also, there are a fair number of abuses of emergency physicians," says Robert McNamara, MD, FAAEM. McNamara is president of the American Academy of Emergency Medicine in Milwaukee and chief of emergency medicine at Temple University Hospital in Philadelphia.
Several small unions now exist
ED physicians often are treated poorly by their employers, McNamara notes. "To have a difficult business environment is added stress to an already stressful specialty. I understand [that] the realities of what rank-and-file physicians are going through may dictate that we have to unionize," he says.
There already are several unions with physicians and residents as members, but they are much smaller than the AMA organization would be. The Dallas-based American College of Emergency Physicians (ACEP) does not have a specific policy on unions, but it does recognize that physicians need more clout in advocating for patients with health plans, explains John Moorhead, MD, FACEP, current president of ACEP. (See story on potential impact with managed care groups, p. 118.)
There are a number of pros and cons of a union, according to experts interviewed by ED Management (see story on potential greater access to financial records, p. 119):
o Pro: Lack of due process will be addressed.
The typical ED contract says you can be terminated with or without cause, says McNamara. "So as ED physicians, we’ve got our own effective gag clause, because if we speak up about closed books or patient care issues, we run the risk of losing our contract."
One study documented that 15% of board certified ED physicians have been terminated without due process, notes McNamara.1 "That’s an appalling number," he says.
o Pro: Patient care may be improved.
There are financial concerns involved with form -ing a union, but 99% of the issue is patient care, says McNamara. "Doctors feel they are being kept from making the right decisions for patients for corporate reasons," he says. "This is not a pocketbook issue, because most doctors feel they are adequately compensated."
The union will be a patient-driven organization, emphasizes Bair. "The issues they’re hoping to combat are inappropriate managed care pressures, inappropriate transfers that are forced, and lack of access to EDs resulting in patients not receiving care."
A union that improves working conditions for practicing physicians also might deliver a higher quality of care for patients, Moorhead notes. "Likewise, better working conditions for residents might improve their education," he adds.
o Con: Strikes are not an option.
"Physicians don’t want to strike, and that would go double for emergency medicine, McNamara stresses. "So the most powerful tool of a union is theoretically taken out of our hands. That has left some people skeptical as to whether we could succeed."
Without the threat of a strike, unions are essentially powerless, says Todd Taylor, MD, FACEP, an attending emergency physician at Good Samaritan Regional Medical Center in Phoenix. "While I am not in favor of physician unions, I do not believe they should enter into such an organization under the premise that a strike is never appropriate," he explains. "To do so will cut such a union off at the knees or force it to eventually break its promise."
Look at what has happened in other countries with physicians and nurse unions, he says. "Virtually all have had strikes or work slowdowns from time to time."
o Con: The status of emergency medicine as a profession could be damaged.
The concept of unions and striking also could hurt emergency physicians’ status as a profession, warns McNamara. "I would hate to see physicians go down that pathway and reduce their professionalism," he says. "If the AMA does it, hopefully they will do it right and will retain the professional aspects of emergency medicine."
Physicians are concerned about what has happened with other professions that have unionized, such as teachers. "The status of teachers has fallen dramatically because of their unions," he notes. "That erosion of professionalism has raised concerns that this could happen to physicians."
o Con: Physician unions are essentially untested in America.
"There is no clear evidence that without significant participation that they can ever be effective," notes Taylor. "In fact, members may suffer not only from significant dues payments but from being shut out of certain markets."
1. Plantz S, Kreplick L, Panacek E, et. al. A national survey of board-certified emergency physicians: Quality of care and practice structure issues. Amer J Emerg Med 1998; 10:1-4.