8 - Unionizing in White Coats: A Doctor’s Role in Collective Action

In every operating room, in every ward, in every clinic, and every team meeting, a silent battle brews. Conflict, negotiation, identity. Welcome to the Scalpel and Sword podcast, where I, Dr. Lee Sharma, physician and conflict analyst, Explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision and power.

Hello, my peaceful warriors. Welcome to Scalpel and Sword. I am your host, Dr. Lee Sharma, physician and conflict analyst, and I am delighted to have on the podcast today. And I'm going to go ahead and say this, even though he's a week away from graduating. Dr. Tarun Ramesh. He is a medical student at Harvard. He is about to graduate and start his internal medicine residency at Harvard at Mass General. We are so excited to have him on the podcast. We were laughing early before. He is an Atlanta native and he went to the University of Georgia for undergraduate. I'm an Auburn fan and my daughter went to University of Alabama. So we have a nice little SEC family going here, which is cool. Dr. Ramesh, welcome to the podcast.

Happy to be here, Lee. I'm so excited to be here and go SEC, but go Dawgs mostly.

You know what, War Eagle? Well, I'll tell you what, we'll leave it at that because we could be here all day doing that, just talking smack. So we'll move on. So the reason I reached out to you is I was doing some research looking at health policy, specifically with regards to physician strikes, and I came across your wonderful publication that was in the January New England Journal of Medicine. And the title of the article, Striking a Balance: Advancing Physician Collective Bargaining Rights and Patient Protections. What prompted you to write and publish this article?

I think it really started with the South Korea strikes. Some of my co-authors, Dr. Hao Yu and Dr. Carmel Seicher, have a lot of deep expertise in this. Dr. Yu's work on the physician workforce has really been extraordinary, and he really pointed out what's going on in South Korea as being very unique. At this point, we had started researching this article maybe in June of 2024. And at that point, South Korean medical residents had been on strike for about 3 months since about February. And so it's quite interesting to see what a substantial duration of time that had been and what that means in this whole moment, especially when we see an increase of unionization amongst Wow.

This whole phenomenon in South Korea is so fascinating, especially when you look at the impetus for the strike. What was the reason these residents went on strike in February of '24? Definitely.

So for some background, the South Korean strikes started when there was a bill passed or discussed in the South Korean legislature about increasing the number of medical school seats. Slots and increasing the caps for enrollment. And on the surface level, from my understanding, was that seems like a very good idea to augment the South Korean workforce, which amongst, you know, high-income countries has one of the lowest physician density populations. The United States is also in that mix of low physician density countries. But despite that increase in medical school enrollment, residents and trainees, as well as some of the older physicians in the workforce, felt that the government was not being really responsive to the reasons why they felt that burnout was so high, why they felt that younger physicians were leaving the occupation and not necessarily working in private practice, not necessarily working in large academic hospitals. And all of these contributing factors led to this desire to make some change. And I think that for the South Korean residents and trainees, this is the way that they felt was the most active.

Wow.

And it's so interesting. I think when you start looking at like, oh, so many challenges they have in South Korea, not just the physician-to-patient ratio, which what you said is one of the lowest, but also the work hours. I mean, Korean residents work 36 hours at a stretch, and that's definitely different than what our 24-hour restrictions are. They also have an extremely high rate of malpractice suits, which I think is just so crazy. Like 1 in 3 South Korean physicians will be sued at some point. In a 5-year window. I mean, it's really, there are so many stressors that are going on. I think this was interesting too, because as you mentioned, this was a policy that was being discussed at the governmental level that they were trying to improve a workforce, but also trying to improve a distribution of specialties. They were trying to get more essential workers into some of these roles. And so this idea of trying to, well, we're just going to admit more people and we're going to see if we can fix this problem.

Right.

When the strike was initiated, there was also some significant backlash from the government, right?

The government gave the residents and trainees a multi-day notice, maybe a 15 or 30-day notice that they would start suspending licenses, that there could be punitive action taken from the state, from the governmental medical boards, and even perhaps criminal charges be brought upon some of those residents and trainees. And let's be clear, while I think a lot of the organization began at the resident trainee level, you saw attending physicians join in, whether they were fighting for the same reason, it's unclear, but it's clear that there was some kind of collective action occurring amongst physicians in South Korea and a lack of forum for them to really voice their displeasure, their concerns about the government's actions.

And the government, as I think that strike grew, Also began to try to attack the residents and the attending physicians in the media. They were trying to cast them as bad guys. These people don't care about you as patients; they're just trying to make money. And unfortunately, I think that also put a lot of the onus on these striking health professionals because they were trying to make them look so putative in the public. I think that was really hard, but it's really cool because you're talking about. This is not the only country, of course, by far this has taken place in. We have seen strikes, resident physicians all over the country and all over the world. And you mentioned the strikes in the UK as well, that the resident physicians in the UK went on strike, not only reimbursement, but also work hour protections.

Exactly. And I think to your first point, there was a lot of public outcry about the South Korean residents going on strike, which really makes us, and I think made me think as a trainee, really about the dual nature of physicians in these kind of organizations about your call to duty, your duty to do no harm, as well as accepting that physician wellbeing is such a critical piece of this and balancing those two, which is I think what this piece really tackles. But to your point about the United Kingdom in January, and the United Kingdom has had a history of kind of trainee strikes at a level that we don't necessarily see here in the United States. In January in 2024, medical residents went on strikes for about 6 days, which is the largest at that point in the National Health Service its history. And that was because of poor compensation really at that foundation level trainees. So those are trainees that are going through residency, very similar to here in the United States. And what I think is unique about those strikes in particular was this is not a kind of one-time thing. You see that the United Kingdom has had decades of austerity. There's this wonderful piece in the New England Journal by Dr. David Blumenthal that talks about the decades of austerity that have hit the United Kingdom, the lack of investment in the National Health Service, and what that means for physician compensation, physician pay, as well as access to care. You now see a lot of individuals in the United Kingdom seeking private care outside of the National Health Service, which a few decades ago was simply not the case.

It speaks to the fact that a lot of these countries that need workforce, they need people taking care of the patients. Unfortunately, sometimes trainee physicians become the easy available resource. We can work them an extra few hours, we can pay them less, and we can actually get more care out of them. And so as you're seeing more governments and especially government-led healthcare systems trying to capitalize on that, the resident workforce is suffering. So this becomes a natural next step to seeing them exercise their voice and their powers. Like, This is not about, not that it's not good for us. It's not good for the patients either. If you've been working for 36 hours at a stretch, do you really think you should be taking care of patients? And so I think you're seeing resident physicians speak up for that. You'd mentioned that I think you're starting to see a rise in this now, but this is actually not the first time I think you've attempted to see organization, especially in this country. But I think you're starting to see more of it now. It's interesting because when you look back at like the AMA, They started Physicians for Responsible Negotiation back in 1999, which was supposed to be under the NLRA, kind of the organizing body for physicians, but it went belly up 5 years later in debt, about $3.6 million in debt. Um, and it sort of has, I think, declined, but now we're starting to see this sort of peak again. Why now? Why are we seeing this sort of rise in unions and why are we seeing physicians, especially residents, starting to strike?

Right, exactly. I think one of the earliest examples of unions in this country is in the 1930s, 1940s in New York, where there was a membership of New York City hospital residents that banded together. At that point in time, which is, you know, quite some time ago, there were residents were expected, or house staff were expected to stay in the hospital throughout the day, throughout the night, were not compensated because it was seen as an extension of their medical school training. For that next level. And so it was really in the '30s, '40s, and then in maybe 1957 when house staff union first really emerged and began to say, hey, we are working, we are employees, and changing that mindset away from just being an extension of medical school, that we have a medical degree and we are still trainees, but not just students anymore. That's when things began to change. There was a lot of discussion with the American Medical Association at that point, and a lot of unionization efforts throughout the country were occurring. And then I think in 1974, Congress approved the healthcare amendments to the National Labor Relations Act, which extended employees of nonprofit hospitals the legal right to unionize and strike. Previously, they had been exempted from this. So, you know, you could unionize if you were at any kind of non-governmental for-profit hospital, but not for the nonprofit hospitals. Which, as we know, are the majority of hospitals here in the United States. And so, you know, that really, Congress allowed that to occur. But the issue is that a lot of house staff were not necessarily covered by this because they were not necessarily seen as employees by the National Labor Relations Board and were deemed as non-employees. And because of that, in essence, what the healthcare amendments allowed hospitals to be, or how union efforts in hospitals looked like, were that the nurses and kind of other employees were able to unionize, but physicians who were in kind of supervisory roles were unable to, and the house staff were unable to until about 1999, which is when the National Labor Relations Board changed its ruling to allow house staff to be included in this interpretation and allowed house staff to formally unionize.

And I think since then, especially post-pandemic, you're starting to see a lot more resident physicians. I think one of the things the pandemic did was expose a lot of those stressors on house staff, you know, in terms of work hours, in terms of reimbursement, in terms of what they've been asked to do. And then after the pandemic, those stressors got magnified. And I think now you're starting to see people say, okay, I'm finding a voice and this is how I'm going to make myself known. And collectively we can actually help ourselves get what we really should be getting for our job as house staff. You mentioned in your paper something about Elmhurst, about Elmhurst Hospital in the Bronx. And I think that was one of, to me, the first big strike that I remember because they were part of that Mount Sinai system. And post-pandemic, and they were ground zero. So much of what I was doing as a clinician was based on what they were doing at that hospital. And yet they were getting paid, I think it was 7 or 8% less than their colleagues in Manhattan. And when they went on strike, one of the things that they actually did that I love is they lobbied for a voice on administrative staff. We just don't want more money or more days off. We actually want a voice in controlling policy in how patients get cared for in terms of ratios, in terms of staffing. We want a voice in that. I feel like that's something too that we're going to see more of, that instead of having the public perception, like in Korea, they're trying to say, oh, these are people who want more money. It's like, no, that's not what this is about. This is about good patient care and having appropriate staffing, reimbursed staffing, and house officers that are cared for as part of that. You have done all this work as a medical student, and now you're rolling into a role as a resident. How has this experience in doing this research shaped what your expectations are going into training?

Right.

Well, you know, I think this brings up a really excellent point. As we were kind of working on this, Boston has seen a lot of unionization in the last few years amongst its house staff. Mass General Brigham, which is the largest healthcare employer in the state of Boston, has its house staff unionized 2 years ago, tentatively reached a deal to increase, I think it was about a 2 or 2.5% increase in the salaries for residents and trainees. Which is remarkable that the hospital administration is working with residents to come together and have that collective voice. I think in the early parts of this pandemic, there was a real fear amongst residents and trainees that there was not enough personal protective equipment going around, that they were working past duty hours, and that this was all straining not only their wellbeing, but the wellbeing of patients and those who they care for. I think that was very concerning. So hopefully that the unionization efforts now can address that part of the trend.

One of the things you talk about in this paper is that when you look at other countries that have experienced strikes, Korea, France, UK, that these are all countries that the United States can learn from in terms of establishing policy. Part of establishing that policy to me in reading your paper is knowing that there are going to be more strikes. It's not a question of, oh, we've had some strikes, we brought attention to the issue, it's over. Oh no, this is something that's going to be an ongoing issue. Yeah, I mean, I think that's a really important point. question and balancing the idea of we need to have physicians have a voice, especially collectively, but we also need to make sure patients are being taken care of. What do those policy points look like?

No, exactly. I think that really draws at this entire point of this piece is that dual purpose that physicians serve both as employees, but also as public servants to the greater population. Some countries have had a much larger and more robust history of physician strike behavior. Countries like France and the United Kingdom have some great things that have come out of them, policy ideas, things like minimum staffing levels to ensure that employers and employees establish a minimum staffing level to allow continuity of care, to make sure that there is no effect on patient health and wellbeing. Other things include a 10-day notice for strikes against healthcare institutions that allows employers and employees and the house staff can work together, make arrangements to safeguard patient care. And adding that minimum level of service will ensure that physicians' ethical duty to serve their patients can be balanced with their duty to themselves to protect against potential allegations of patient abandonment by state medical boards. There are also things that some countries have done that I think we can veer away from. South Korea allowed the penalization, including the suspension of medical licenses or incarceration of physicians who refused the government return to work orders. And they backtracked on that after potentially thinking about using these laws due to public outcry. But that kind of punitive action just further damages that employer-employee relationship, further compromises working conditions, further exacerbates burnout and job dissatisfaction. And so I think we can take protections through state medical boards to make sure that legal charges associated with union activities don't affect licensure. Making sure that there's not backlash against trainees as well, because of course, as we know, that trainees are very vulnerable in their career relative to other physicians because of their— in the process of their board certification. As well as I think that we need to consider that unionization, while allowed through the NLRB for house staff and residents, is not really the same for supervising physicians. So the NLRB excluded physicians or attending physicians who are in charge of trainees from being able to unionize. We see this trend with the pandemic, of course, but there's also this kind of underlying current that we can talk about further through the financialization of American healthcare system, and that physicians are really just not in private practice anymore. You see a much larger amount getting acquired, whether through hospital practices, About 33% of physicians were in a non-hospital-based practice in 2012, and that's risen to about 80% in 2020. So there's a lot of these trends that are occurring that with the pandemic kind of affects how physicians interact with their employer. That's more than just the house staff, but it also includes physicians as employees in general, regardless of whether they're a supervising attending or not.

Absolutely. And I totally see, as we see the shift to more employed physicians, shifting more at 80%, where 20% of us are considered independent. But that was always a roadblock to unionization because if you were an independent physician and you tried to unionize, there was all this idea that we could be antitrust, you could price fix. And that was something that from an economic standpoint was not going to be permitted. So now that you're seeing more employed physicians, you are going to see more of those unions, but also too. You are running into more of these problems with hospitals that have these physicians that are pushing them to work longer hours, that are not enforcing appropriate staffing ratios. And so this is the only way they can talk. So I'm going to throw back a little bit because I'm significantly older than you are. So I trained back in the '90s. My parents were physicians who trained in the '60s. So I remember when my parents literally lived 100 yards from the hospital. They were truly resident physicians. Like when dad was on call, he literally could walk the 100 yards as a general surgeon to his hospital. Mom was pathologist, didn't happen as much for her, but I remember that. But I'm also old enough to remember what life was like before work hour restrictions. When I was a resident, we didn't have that. So it was not unusual for us to pull a 30-hour. It didn't happen very often, but it did happen. It was very interesting watching that culture shift.

Yeah.

When ACGME introduced the work hour restrictions, and there were definitely some doctors of my generation who said, I don't know why we're doing this. We didn't do it. Why are they doing it? And yet now we're seeing countries, whole countries of physicians that are going on strike because they don't have something we have. These residents are being pushed in a way that we know is not good for them, but it's also not good for their patients. So do you feel like Maybe having some of these policies already in place may be part of the reason why we haven't seen these large—

I totally agree. I think in some ways the ACGME has really protected residents', uh, wellbeing. I think they can go further, of course, but I also think that the landscape of American healthcare has changed a lot in the last 2 decades. You see the proliferation of the electronic medical record. You see the passage of the Affordable Care Act. Now in Boston, for example, and I'm sure across the country, Since COVID huge backups in nursing homes that are creeping into the hospital. It looks like there's a lot of hospital beds overfilled. A lot of hospitals are at capacity, and because of that, the lists are longer perhaps. And I think that the federal government is taking steps to deal with this. They've increased residency slots by 1,000 over a 5-year period, predominantly in rural and underserved areas. But there are things that we can still do to support the workforce. And I do think that the level of corporatization and financialization that we see in the United States is perhaps greater than the corporatization that we're seeing in other countries so far. And I do think that unionization offers a voice, a distinct voice, especially when you see like physician ownership of hospitals, things like that, where we're not really seeing physician voices necessarily. In making decisions at a business level, at a like administrative level that hospitals are okay with. And so I think unionization efforts is one way to bring that voice into that discussion. On the other hand, I think there are some drawbacks. There's potentially higher costs for healthcare, potentially loss of autonomy for individual physicians, as well as maybe inequities between kind of physicians who are independent or in private practice and those who are employed. There are also alternatives to physician unions as well, including medical staff committees, and that allows you to have kind of a voice in hospital leadership without necessarily being a formal union and having the kind of the protections and rights that kind of come with that as well. And so all I have to say is I think that there are, you know, this is a response, a very clear response that physicians do need more voice in kind of policymaking and hospital administration to protect patients as well as protect their own wellbeing.

One of the things that you talked about, I loved in the article that you just mentioned, was that there's not just one avenue to physicians to make their opinions and make their voices known. It doesn't have to be just unionization. It can be getting involved in the hospital through medical executive positions, even doing organized medicine, MA specialty organizations. Those are ways you can help to develop policy that can influence the way that healthcare is delivered in our country. So there's a lot of different ways to do that. One of the things that I so enjoy looking at your CV and look at the work that you've done, you've done a lot of work on economics in hospitals and how hospitals work from an economic standpoint. I feel like you've spent a lot of time looking at that. A lot of the countries you talk about in the article, UK, France, South Korea, those are all nationalized state-run healthcare systems. So the fact that we don't have a state-run insurance program or a federal uniform health system, that we have independent hospitals, does that make it more likely that we're going to see more union activity? Because now that you're seeing sort of these different hospital systems being run so differently?

I think perhaps, I don't know. If that is necessarily true. I think in some ways there are a lot of heterogeneity in how hospital administrations run their hospitals, and in some ways residents may want to unionize. For example, I think the New York Presbyterian hospitals that include Cornell and Columbia have not unionized, and you haven't really seen unionization in Georgia as well. And do I necessarily think that hospitals that have unions are doing a worse job for their residents? I don't necessarily. I do think that perhaps there's a lack of inclusion of resident voices, but I also think that all of this just speaks to a broader frustration with how hospital leadership have dealt with kind of trainee voices. And I think it's hard in a lot of ways for us to kind of get a better sense of what this means for patients long-term. Because on one hand, obviously, if physicians are striking, You're gonna see delays in care. And in, in the US, I, you know, I try to get a dermatology appointment and it takes so long to get one. And, but, you know, the research that we've seen is very limited in the United States. And I think that is a key part of this, right? We just don't know what physician strikes look like. All of the research has been done in the '70s when maybe this was more common and from other countries. Our hope is once we have a sense of What does this look like in the next few years? Can we look at the strikes that have occurred in this 2-year period and see what the implications of that are for patient care?

Yep. It's going to be, as we get more and more unions and as we're seeing more and more strikes, I think we're going to have, like you said, absolutely more data to see the ripple effect of what has occurred as a result of those strikes. And it's not just ripple effect of what's happening with patients. It's also the ripple effect of what's happening with clinicians. If clinicians are striking because of lack of resources, because of burnout, because of lack of reimbursement, because of work hours, are those things improving after that strike has occurred? Are these things that we're actually seeing get better? And as we get more and more of that data, I think we'll see more and more one of two things, or possibly two things. We'll see those things get better because they'll have to be addressed. But we'll also see larger healthcare bodies making policies like, okay, this is an overarching problem. Burnout is an issue. Moral injury is an issue. How can we address this? And one of the things that I saw in Elmhurst that I was very impressed with is I think on some level, the hospital did start to take responsibility for what those residents had gone through. They actually said, okay, we have not addressed the fact that we were complicit in the struggles you've had, it's not just about paying you more money. It's about giving you more power. And strikes are almost all— and tell me what you think. Strikes are so much about power. This is what we are doing to reclaim a voice. So I agree with you. I think it's gonna be really cool to see what happens in 10 or 15 years when we see what has happened as a result of those strikes. I also really do love that You are bringing the government into this problem. It's not just a hospital problem. So going forward, I hope you're going to continue to be active as a resident. You've been so active already as a medical student in terms of your publications and also your research. So let's just say, for example, you are sitting down with a congressional committee and they are asking you, okay, Dr. Ramesh, we really want to know what policies do you think that we can set to improve resident workforce conditions and patient care? In the next 10 years, you have a golden ticket. What would you say to them?

One of the things I think about is this, you know, with the Affordable Care Act's ban on physician-owned hospitals, I think that's a very interesting thing that occurred due to a lot of like intense lobbying from the American Hospital Association, as well as nonprofits and for-profit hospitals where we're seeing a decrease in kind of the physician voice in some of these aspects. And in a world where private equity, where you see large for-profit hospital chains gobble up smaller independent practices, you're losing that physician voice. And I think that's what this whole unionization effort, as well as in the response to the pandemic, is really talking about, bringing back collective voice of healthcare to physicians and their patients rather than someone in some firm somewhere, right? And I think that physician-owned hospital ban should be one of the first things. To go from that aspect. Not only would we be introducing a potentially more competitive kind of facility in place, another way of ownership that can bring some competition to a heavily concentrated healthcare market, but we're also kind of symbolizing this idea that we're valuing physician voice and physician kind of interests and their relationship with a patient at a very fundamental policy level. That I think is missing from this conversation. Another thing is thinking about how we kind of financing graduate medical education now, which is through Medicare. And what you see is actually one of the largest graduate medical education facilities is not a large hospital. It's HCA, which is a for-profit hospital chain. And you see that there's, you know, clear financial incentives to be training residents. And why is that? Because they make your hospital money. They were taking care of large patient volumes, doing, you know, significant amount of hours that at the end of the day, advanced practice practitioners are just not reaching, or perhaps that they don't have the training enough to do. And so that's a very delicate balance to hold as well, right? How are we incentivizing graduate medical education to be the best for trainees rather than be necessarily the best for a large for-profit chain?

Absolutely. Wow. I think when you talk about this ban on physician-owned hospitals and you look at the research you did in South Korea, that was one of the biggest things that stood out to me was they specifically did not include clinician voices in making this policy. And if you're blocking physicians from having input on patient care, it's what we do. We know we're in this world. You are depriving yourself of a really huge resource. And so I think that's That's such a great point. Um, and I hope, you know, the points that you're talking about, I think become really good lobbying points for us working in healthcare policy that we can continue to push and advance because you're right. It's going to be your voice. People like you coming into the profession, which gives me tremendous hope. Um, watching people like you come into the profession just makes me so happy because it's just going to enhance the care of patients and It's just an honor to have people like you as colleagues, and it's, it just brings me a lot of joy. But I also think that we are going to use your thought leadership to improve patient care, not just for the patients, but also for the clinicians that are in the system. I think so many people are going to benefit from the work that you've done. Um, if people want to reach out to you and have questions about your article, how can they reach you?

Of course. Uh, my Twitter handle is TarunR99. Happy to connect with anyone. And I do wanna give the work that I've done is obviously not in a silo. It's really built upon the, the physicians and the trainees and, you know, the nurses and employees of these hospitals, as well as the patients that have kind of advocated for physician wellbeing for decades. And I think it's their kind of leadership, the activists, uh, and Mass General Brigham. who worked to unionize their hospitals, the residents. And I remember being a medical student on rotation there. It was very controversial time amongst the residents, but it was really wonderful to kind of see them band together. And some of the residents at that time, I think, did such a wonderful job, and it was very encouraging to see that camaraderie and that spirit of medicine. And it's a beautiful thing to witness.

Wow. Absolutely. Dr. Tirunamesh, thank you so much for being on the podcast. Your time has been just Completely wonderful, and all your work has been so valuable. So I look forward to see what you're going to continue to do in the future. All of you who have joined us on Scalpel and Sword, thank you so much for being with us. And until next time, peaceful warriors, be at peace.

Every episode is an invitation to speak, to negotiate, to choose. I'm Dr. Lee Sharma. Join the di. dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword is not intended as medical or legal guidance. For personal matters, please consult Consult a qualified professional.