Wednesday, June 3, 2009

PHYSICIAN UNIONIZATION: A Model or a Master?

THE UNIONIZATION MODEL: Incongruent with the Physician Professionalism

Nearly 100% of graduating medical students today pledge some version of the Hippocratic Oath, which includes the following passage (from the Classical version): “What I may see or hear…in regard to the life of men which on no account one must spread abroad, I will keep to myself…” (Oath Today 2003). Only two other learned professions take such an oath upon their professional “coming of age” and live by that oath for as long as they practice their art. Even in our everyday language, our definitions in addressing these honorable citizens hold them sacred by prefacing with “Doctor”, or suffixing with “Esquire”, or honoring as “Reverend”. According to George Lundberg, past editor of Journal of the American Medical Association (JAMA), these three profession are held above all others: The Physician, The Lawyer, and The Clergy. Dr. Lundberg calls for a return to this professionalism (Lundberg 2000).

The primary reasons people become physicians, continues Dr. Lundberg, are (2000):

1. They have a desire to take care of other people. They have a desire to serve.

2. They are intelligent. These people always got A’s and they enjoyed school. They have to in order to accomplish the academic rigors just to enter medical school. They are knowledgeable, erudite, learned, and licensed.

3. They are independent people. Most claim to look forward to opening their own practice, and have always been autonomous. They are leaders, making the decisions rather than taking the orders.

4. They want to make money. They have an entrepreneurial streak. They want to be successful, financially independent, and live the assumed lifestyle of a Professional.

These are also the fundamental definitions of the Profession, too. The reasons they became doctors and the reasons they remain doctors—the fundamental rationales of why physicians should not unionize: The basic definitions of the two entities, “physicians” and “unions”, are incongruent.

The terms that describe physicians are philosophically, dynamically, and practically opposed to those used to define Unions. The ethical dynamics that hold physicians accountable and organized are dichotomous to the political bureaucracy of a Union, by definition designed to defend workers who cannot defend themselves--either through lack of credibility, intelligence, leadership, or social position.

Among Lundberg’s many claims is the stern warning to the American Medical Association (AMA) to step in and reclaim these ethical definitions of healthcare, “or someone else will” (Lundberg 2000). Commerce already has a firm grip on healthcare. Unions have their foot in the door, and if the Physicians or the AMA do not shut it, it will swing wide and far, taking with it the last shred of the patient-physician relationship: the art of healing and the miracle of that art. And the practice of medicine is an art, no less than painting or poetry or writing or any other abstract endeavor traditionally ordered by guilds, not unions.

The promise of guaranteed payment through plans like Kaiser, Blue Cross, Medicare, Medicaid and Health Maintenance Organizations (HMO’s) appeared an intelligent choice for physicians traditionally organized under a patient-physician fee for service arrangement. The 20th Century brought many philanthropic, political, and philosophic burdens on physicians. The fantastic growth of Southern California lead to the development of Kaiser Permanente’s managed healthcare for poor migrant workers who came west to build Los Angeles. In the 1960’s Medicare was legislated, along with tax-credit incentives, offsetting taxes from large incomes earned through employer-based healthcare insurance. Opening the door to managed care seemed a natural progression in the 1980’s. Lest frantic physicians today blame anyone else but their mentors, clear memories remain of the number one buzzword among the healthcare industry during the ‘80s from professional conferences to community mixers: “HMO”. Now, in regret and remorse, they have learned what was given (power in patient management) and what was lost (trust in the patient-physician relationship) in exchange for a guaranteed wage. Yet physicians have something that no government or union or corporation can take away from them: A license to practice medicine. They just need to be collectively reminded of that…not collectively represented in bargaining that is irrelevant to the profession. Physicians are the professionals. They hold the power, because they hold the knowledge and they hold the license.
Arguments for physician unionization focus on the issues of power; and it is true that unions hold power: political power, in the ability to form Political Action Committees (PACs) and influence legislators; bargaining power, in number and presence acceded to them through proxy; economic power, in the power to strike. In defining these powers, though, political power and bargaining power is incongruent in its duplicity, for the AMA also holds such political power and the physicians keep the knowledge--an important consideration in the discordance of the power to strike. In this day and time, it is an empty power when applied to certain patriots, as the Homeland Security Act of 2002 and imminent threat of biological warfare would surely prevent physicians from striking. After all, who would take their place? Not the janitors, who are, by the way, unionized.

And well they should be. The Service Employees International Union (SEIU) is a large and effective union that is appropriate for those healthcare workers it protects. Once upon a time, if you worked in the healthcare industry, you were also privy to the services of the physician you served. In the days of managed healthcare, there is no such privilege, and even nurses worry about access to healthcare (Stephenson 2003). SEIU’s web site verifies that insurance and medical access for a healthcare worker is of issue, claiming that “janitors rely on over-the-counter remedies, clinics and prayer.” This scenario is not consistent with the public perception of a practicing physician (Standing Up…2003). Doctors, even if at a minimum technological level of diagnostics and hands on treatment, have the knowledge and skill to provide healthcare to themselves and their loved ones under any circumstances.

The SEIU’s unionization of sub-professionals in the healthcare industry has brought a model of union organization into the physicians’ workplace, but it is the wrong model. In “Managing Professional Work: Three Models of Control for the Health Organizations”, W. Richard Scott demonstrates, pre-HMO, that Physicians operate under a model of “Autonomous Professional Organizations.” They are externally authorized (governmental licensing requirements), formalized (academic credentialing and ethics oaths), and peer-group controlled (the AMA and other physician support organizations). In this way, physicians are accountable through organizations, oaths, and peer or government sanctions. An advantage of this model is that the responsibility is placed on the person with the greatest control, which is compatible with the traditional view physicians have of themselves, as well as how people view physicians (Scott 1980). Peltzer, Boyt and Westfall (1997) strategically appeal to a business-motivated audience such as administrators, marketers, and human resource managers; but, their underlying warrant is salient and supportive of the general consensus that the patient-physician relationship is of great importance to the health of the patient and the professional fulfillment of the physician.

There are many good reasons to unionize, but to ‘regain power never lost’ seems a con game on the desperately confused. Physicians traditionally passed down their trade, including the business and ethics of the art of healing; yet, in this day of advanced technology and light-speed communication capabilities, physicians have been infected with apprehensiveness and self-doubt.

The truth about unionization is difficult to decipher, as unions are not tied to the ethical practices of the sacred professions. Whether they are pursing physicians or physicians are truly unprepared to meet the scientific, technological and economic challenges of the 21st Century is difficult to distinguish. Unions historically respond to desperate industry employees’ dissatisfaction with working conditions, pay, overtime, and job security. They also seek out the desperate in brilliant forensic arguments to sway even the most autonomous of physicians. Physicians need only check their Palm Pilot for a review of the AMA ethical guides to come back in favor with the ethics of the profession (AMA 2003).

Clergymen who push their religion for crystal cathedrals are considered dangerous fanatics and violation of ethical codes among priests is grounds for ex-communication; derogations abound about “ambulance chasing” lawyers and disbarment is the punishment for unethical legal tactics; an incompetent doctor is called a quack, but should they become unionized, they will simply be defined with “you’re fired”.



WORKS REFERENCED IN THIS BLOG

The White House. http://www.whitehouse.gov/deptofhomeland/bill/

AMA will provide electronic alerts to physicians (2003) American Medical Association News Release http://www.ama-assn.org/ama/pub/article/1616-8001.html

AmedNews.com, the Newspaper for American Physicians. "The National Labor Relations Board has ruled that residents at private hospitals are employees -- with the same right to unionize as residents at public hospitals

Hippocratic Oath – Classical Version. Survivor M.D. Nova Online.

Lundberg, George, M.D. (2000). Severed Trust: Why American Medicine Hasn’t Been Fixed. New York: Basic Books.

Peltier PW, Boyt T and Westfall, JE.

Scott, W. R. (1982). Health Services Research 17:213-240.

Service Employees International Union Justice for Janitors. http://www.seiu.org/building/janitors/

The Hippocratic Oath Today: Meaningless Relic or Invaluable Moral Guide? (2003). Survivor M.D. Nova Online. http://www.pbs.org/wgbh/nova/doctors/oath_today.html
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