John La Puma, M.D.

John La Puma, M.D.

The American Medical Association has voted to form a:

  1. Wednesday morning golf league
  2. Drive-through morning checkup service
  3. National doctors union
  4. Frequent-patient program
          — Chicago Tribune, 6/27/99

This is the public's attitude regarding physicians and unions. For anyone who doesn't believe it, think about basketball and the public's tolerance for star salaries. Do individuals do well? Does the players' union help? Are players considered "professional athletes?" Yes, yes, and yes.

Why did the AMA give its stamp of approval to the union label, and create its own? What does it mean for managed care, and for doctors? What does it mean for medical ethics?

Some numbers

To start, three facts: The AMA doesn't represent all physicians (barely one third of them); even if every physician belonged to the AMA, only about a seventh would be eligible to join the AMA's union, and most doctors are barred by federal antitrust law from bargaining collectively.

  • The AMA says it did it for patients. And if you believe that, the Teamsters care just about cargo, and the Mineworkers about ore.
  • The AMA did this not for patients, but for the fee schedule doctors negotiate with managed care organizations. End of story.
  • The AMA union can't strike, which is a union's biggest weapon. Note that when physicians did strike at a New York City teaching hospital 24 years ago, the AMA actually endorsed the strike, something it hasn't done since. Not striking has some advantages, but not bargaining advantages.

Implication for managed care?

Managed care wins if doctors unionize. If the AMA union holds, then its doctors are unionized laborers who have vowed not to strike. The costs managed care incurs while fighting them are passed on to employers, employees, and health plan members.

Managed care has helped whom to date? Certainly large employers, whose costs have been driven down, and who wanted managed care in the first place. And what is one of the largest employers nationally? The government, of course.

Managed care continues to be a source of evil in the public's eye, though there is little government, employer, or public sympathy for doctors and their $200,000-per-year plight. Patients dislike managed care just as much as they dislike government. And patients are getting more fed up as the millennium approaches.

And for doctors?

Managed care has made money by reducing the fees it pays to doctors, dentists, hospitals, pharmacies, and home health organizations. It asks them to do the same amount of work — or more — for less money. Doctors have little data and less expertise in these negotiations, and have consistently come out badly.

As managed care has gained power, the number of managed care companies in urban and suburban areas has declined. In Albuquerque and Minneapolis, for example, there are only a few large managed care companies. In a way, those are company towns, and if you want a job in health care, you talk to just one or two employers. Just like the autoworkers or the steelworkers.

The uneven playing field on which doctors find themselves in negotiating fee schedules makes collective bargaining seem attractive. Collective bargaining — if doctors are prepared to strike — should give them power to negotiate wages, benefits, and working conditions.

Forming a union is a reaction to this uneven field. It suggests that managed care calls all the shots, and only by organizing can doctors gain equal footing — in fighting utilization review, in feeling as if we are not just interchangeable widgets, in gaining a strong voice without having to challenge an internal corporate Goliath. These points resonate deeply with physicians, but they are not the main points.

The main point is, pure and simple, that the system engenders distrust, and that money has something to do with it. When patients paid doctors directly for services, and the flow of patients came from the community, who needed an intermediary?

The AMA should stop pretending that its major concern is the welfare of patients and the autonomy of its members. It's not. It's better terms for its members.

Whether forming a union will help physicians or just help unions (we're now solidarity brothers with guys who drive 18-wheelers and wear worn tool belts) remains to be seen. A union is probably just one more roadblock doctors will use to try to stop the runaway Hummer of managed care.

The effects

Unionization doesn't change the doctor-patient relationship, or the ethical principles that govern it. It could change how, how much, and when doctors are paid for doing what they do.

Unions ensure that individuals are treated fairly. If gigantic corporations treat professionals badly, and we cannot defend ourselves because of our commitment to our work, then joining a union is the right thing to do. It's just not the main thing to do.

What AMA members decided

Here is the text of the AMA's E-9.025 Collective Action and Patient Advocacy, issued in June:

"Collective action should not be conducted in a manner that jeopardizes the health and interests of patients. Formal unionization of physicians and physicians-in-training may tie physicians' interests to the interests of workers who may not share physicians' primary and overriding commitment to patients and the public health. Physicians should not form workplace alliances with those who do not share these ethical priorities.

"Strikes reduce access to care, eliminate or delay necessary care, and interfere with continuity of care. Each of these consequences is contrary to the physician's ethic. Physicians should refrain from the use of the strike as a bargaining tactic.

"There are some measures of collective action that may not impinge on essential patient care. Collective activities aimed at ultimately improving patient care may be warranted in some circumstances, even if they create inconvenience for the management.

"Physicians and physicians-in-training should take full advantage of the tools of collective action through which to press for needed reforms. Informational campaigns, nondisruptive public demonstrations, lobbying and publicity campaigns, and collective negotiation are among the options available which do not limit services to patients.

"Physicians' collective activities should be in conformance with the law."

John La Puma, M.D., is a Chicago-based internist and author of Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics, Hatherleigh Press, New York, 1998. He is director of the C.H.E.F. Clinic at Alexian Brothers Medical Center in Elk Grove Village, Ill.

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