By: Dr. David Schwartz
Senator Elizabeth Warren once said, “If you don’t have a seat at the table, you are probably on the menu.” While somewhat amusing on the surface, Warren’s comment cuts to the core of why my colleagues and I decided to form the first hospitalist specialty union.
In 2014, a consulting firm was hired to review our hospitalist program. We were a 38-member group serving a 382 bed referral hospital – one of only two in our community of 200,000. We care for 50-60% of inpatients at any given time and average 35-40 admissions – and sometimes over 50 – in a 24-hour period. Our census had been growing significantly for some time without a comparable increase in staffing. The occupancy rate of the hospital consistently reaches 90-100%. The only other hospital is a 115 bed community medical center.
We were told that the purpose of the review was to affirm the great work we were doing and to help us target areas for improvement. In their final report (based on a number of misinterpretations of data as well as some erroneous data), they concluded that we were an underproductive group with suboptimal performance. We had to struggle to even gain access to the report. Their conclusion led directly to the hospital CEO’s decision to seek an RFP for hospital services. We were given no warning; no opportunity to improve; no grace period in which to improve, and no opportunity to challenge the data and its interpretation. The CEO simply presented his conclusion to hospital board and the process took off. A Request for Proposals (RFP) was sent out to prospective management companies.
We were caught completely by surprise. Our hospital had been consistently profitable. In review of the raw data from the report, we found that our metrics were at or above national medians. Despite this, the administration still concluded that the hospitalists needed to be outsourced. If our numbers were consistent with comparable hospitalist services, why were we being outsourced? We began to suspect that the motive was money.
In a meeting open to all medical staff and referring physicians, the medical group CEO admitted that the reason for outsourcing was financial. His exact words were, “We are trying to get your budget from 6 million dollars to 3 million.” He later added that these were not exact numbers, but used as an example.
This is not the first time that hospitals in this geographic area had attempted to outsource hospitalists. The other hospital in town had tried two different national management companies to manage their hospitalists with disastrous results. A high turnover rate, low patient satisfaction, and chronic physician shortages drove the hospital to abandon the outsourcing of doctors. Several hospitals in neighboring counties also tried, and then abandoned, the management companies in favor of hospital-employed physicians.
System wide, there was also a movement by administration to centralize and standardize decision-making. The physician leadership groups were dismantled and replaced with a top-down management structure, centered at corporate headquarters out of state. Administrators increasingly interfered directly with physician decision-making. This led to a profound lack of autonomy and threatened our ability to advocate for patient safety. Physicians were losing their voice.
When faced with being outsourced, we had three choices: 1) Leave; 2) Stay and hope that things wouldn’t be so bad; or 3) Stand our ground.
Over a third of the practice left, feeling powerless over the situation.
Leaving would have been easy. It seems to be the usual custom in situations like this. Many of us have left jobs before. But this job was different. Many of the physicians in this group have deep ties to this community. We would have left our community, family, and friends unprotected and at the mercy of an out-of-state management company employing doctors that have nothing invested in our community. Those of us who stayed became angry. We decided to fight.
The idea of unionizing took some time to sink in. None of us had ever considered unions before. It also took a while for us to realize the truth: we were no longer independent, respected professionals. We were employees.
As a union, we have rights under the National Labor Relations Act (NLRA) denied to us as individuals. The myth about unions is that their greatest and only power is the ability to strike. While this option does exist, none want to exercise it. Our dedication to the safety and well-being of our patients is our highest priority. We operate with the hope that things will never get to that point.
Prior to unionizing, it was much easier to terminate a physician. While we do have contracts, physician employment has been terminated at our institution without warning. The reason given is “behavioral problems,” which is code for “you are not doing as you are told.”
There are benefits to unionizing, many of which are subtle but powerful.
- Collective Bargaining: In addition to the ability to negotiate a contract for the group, any significant change to working conditions must be bargained with the group. This provides a structure for communication between administration and the union. Want us to see all of the Cardiology admissions? Certainly. But we will need more staff. Want us to become universal providers? Let’s come up with a business plan. The greatest benefit about being in the union is that it gives us a seat at the table in discussions regarding our practice. It puts a firewall between us and the top-down management style of most hospital corporations.
- Job security: Physicians have been terminated simply for standing up to administration. Under the NLRA, employers need cause for termination. This is one of the greatest benefits of a union. Seven Tests of Just Cause (a rather dramatic title, I know) determine whether or not a termination is justifiable:
Was a rule broken? Was the rule clearly written? Was adequate notice of the rule given? Was this thoroughly investigated? Are their processes or procedures associated with the rule? This protects the physician that is doing their job from being terminated without process.
- Professional support: Unions have legal counsel, research departments, publicity departments, and scores of people knowledgeable about healthcare law, labor law, etc. We have benefitted from the collective knowledge and experience of scores of many highly trained professionals. You will never have to go it alone.
- Solidarity with one’s colleagues: The ability to speak with a single, strong voice. It is easy to isolate and intimidate a single employee. It is much more difficult to do so with a large unified group.
- Solidarity with other unions: Unions stick together. We are aligned with the three other groups represented by unions in our hospital: The nurses, the ancillary staff, and the stationary engineers. Currently our union has only 30 members. But 2500 of our closest friends are standing behind us. We are all in this together, advocating for safe patient care and our safe working conditions.
- Concerted effort: We have the ability under the law to take actions as a group. For example, working to contract (everyone agreeing not to work more shifts than contracted), to picket, and as a last resort, our right to strike. While we are loath to strike, it is an option that can be used only in extreme conditions.
Once the unionizing process was underway, we found that we were free to speak up, speak our minds, and challenge our employers when we felt conditions were not safe. People who were normally silent and afraid found voices they never knew they had. We are still accountable for doing our jobs and practicing medicine in a safe and effective manner consistent with standards of care and our medical staff bylaws, but the change was palpable.
Our small but determined group had successfully thwarted the efforts of two large corporations. In doing so, we helped create the opportunity for other specialty groups to unionize.
Although our contract negotiations are ongoing, we are actively discussing issues such as staffing, surge plans, and professional autonomy. Since unionizing, we have regained a very strong say in how our practice is run. Additional team members have been added to help reduce the individual census. We are now in regular, direct communication with the administration regarding issues in our practice. In our contract negotiations, we are bargaining for accountability of administrative decisions. And they are listening. Not because of threats or intimidation, but because we have found our way to the table.
Why could this be important for the future of hospital medicine? In a profession that is becoming ever more corporate, run by business people who are primarily focused on profit margins, we have become a powerful voice for our patients and our community. With the legal backing of federal law, we can now advocate for patient safety, and safer, saner working conditions for physicians in our group. Our patients and fellow hospitalists will no longer be subjected to the whims of an ever-changing administration. We have taken back control of the narrative that guides our job. We have the chance to reclaim our profession.
UPDATE: Click here for recent developments as the union engages with the hospital to resolve the contract dispute. Dr. Schwartz will follow up in future posts as events unfold.