When you went to medical school, did you ever think you’d be asked to join a union? If you are like us, neither did we – most of us did not think of ourselves as future members of a physician union. Lately, there are more frequent discussions about anesthesiologists unionizing and using collective bargaining to address our professional concerns. We have all seen recent examples of residents from different specialties forming unions. The Association of American Medical Colleges (AAMC) reports that the pandemic has accelerated this movement (asamonitor.pub/45fwGMa). With more residents entering their practices already familiar with unionization, and the number of employed physicians on the rise, it is not surprising that collective bargaining is often discussed in physician circles. This is an important topic, and the issues related to physician anesthesiologists unionizing, both positive and negative, must be considered.

Collective bargaining and unions result from the National Labor Relations Act (NLRA), passed by Congress in 1935. This established the policy of the United States to support collective bargaining in the private sector by allowing workers to organize and seek better working conditions without fear of retaliation (asamonitor.pub/3VzS5wk). Collective bargaining does not require the formation of a union, but that is often the result. The National Labor Relations Board, which is the federal agency that protects the rights of private employees to bargain collectively, grew out of the the NLRA. Traditionally, physicians have not been members of unions because they owned their own practices or were independent contractors. The structure of physician practices, however, has changed. According to Avalere Health in 2022, 74% of physicians are employed by hospitals, academic centers, corporations, or medical group practices (asamonitor.pub/3XaWoj1). The U.S. Bureau of Labor Statistics reports that over 33,000 anesthesiologists are employed by health care companies (asamonitor.pub/3Rm0HUN). Increasing physician employment – together with the consolidation of large health care corporations, plus ongoing workforce challenges – have led some physicians to reconsider physician unions.

Why haven’t physicians formed unions before? Self-employed, independent, or group-owner physicians do not qualify for union membership. The primary requirement for forming a union is that the members must be employees. Employed individuals with supervisory roles cannot bargain collectively as part of a union. Physicians have frequently been considered supervisors because of their roles in the hospitals, particularly with the medical supervision of nonphysicians. In order to support union formation, the NLRA gave some relief to physicians in their definition of supervision:

“Any individual having the authority, in the interest of the employer, to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward, or discipline other employees, or responsibility to direct them, or to adjust their grievances, or effectively to recommend such an action, if in connection with the foregoing the exercise of such authority is not of a merely routine or clerical nature, but requires the use of independent judgment” (asamonitor.pub/3VzS5wk).

There are ethical and professional considerations. Physicians have questioned how their patients would perceive them as union members. Would this diminish their professional stature? Physicians value patient care first, but are their employers using this against them when negotiating? Ultimately, the most critical factor when considering collective bargaining should be the impact on patient care. Collective bargaining may benefit patient care by protecting appropriate supervision ratios or limiting needless clerical duties. However, the imposition of practice requirements could decrease the number of hours a physician can work, leaving gaps in patient care. On the other hand, potential improvements in work-life balance and a decrease in physician burnout rates because of union efforts could translate to improved patient care. Ultimately, it may come down to ethical considerations as to whether the presence of physician unions is a net positive or negative for patients. This determination will be different for each location and ultimately up to each individual physician to decide.

Unionization is not perfect. Collective bargaining means the physician may lose their individual right to negotiate and may not be able to effectively “cut their own deal” with their employer. Unionized physicians may find themselves answering to both an employer and to the union. With the loss of autonomy, unionizing may make our profession less fulfilling, leading again to physician burnout. Unions require membership dues and fees. Being an organization itself, there is the potential for competing interests, which adds more red tape to already bureaucratic organizations. What happens when there are interests that one group of union physicians wants to focus on, but another medical specialty has a different hierarchy of needs? Who makes the decision as to which gets priority? It is possible a union may add to the complexity of the practice environment, leading to further negative impacts for the physician.

When we think of unions, we often think of strikes. Strikes, or work stoppages, are the ultimate bargaining chip for unions. A physician strike and jeopardizing patient care is not palatable for most physicians. Aside from our professional duty and our conscience, the American Medical Association forbids the withholding of care to patients (asamonitor.pub/3yOtFWW). AMA policies support unionization, but they do not support placing patients in the middle of disputes (asamonitor.pub/3yOtFWW). Congress also recognized the potential for disruption of patient care from health care strikes. In 1974, the NLRA was amended to include a provision that requires unions to give a 10-day notice before an organized work action. This notice would allow the institution to make plans in order to preserve safe patient care (asamonitor.pub/4aXmadA).

A full vetting of the pros and cons of physician unions, specifically for physician anesthesiologists, is beyond the scope of this article. Ultimately, the priority should be how it would impact the patient. How will more physician unions impact the cost of care? How will nonphysician anesthesia professionals view, and likely manipulate, public relations messaging surrounding anesthesiologist unions? These issues are yet to be determined. In 2023, Hendrix et al. reviewed many of the opportunities and challenges related to physician unionization and concluded that more open discussion, data collection, and study are needed. Before joining a union, we must weigh the risks and benefits of participating in collective bargaining (Anesth Analg December 2023). This includes patients, physicians, and health care organizations (Anesth Analg December 2023).

Would joining a union take away the need to join ASA? We think not! It is the continued work of ASA in the areas of economics and advocacy that supports reimbursement for anesthesiologists and protects the safety of our patients. With improved payment for anesthesia services and financial literacy, anesthesiologists have more negotiating power with their employers. This can be the result with or without a union or collective bargaining. ASA supports anesthesiologists and our patients. ASA membership includes all voices when making decisions affecting our specialty. Our ASA membership umbrella is very large. Just as it is with other polarizing issues, our membership has diverse opinions on the topic of collective bargaining and physician unions. It comes down to just one fact, which was highlighted by ASA Past President Roger Litwiller, MD, in his address to the 2004 House of Delegates: “It’s all about the patient because we have no other reason to exist.”