Labor unions gained momentum in 2023 as high-profile strikes by auto workers, Hollywood writers, and Kaiser Permanente health care workers garnered headlines.¹ That momentum also extended to physicians, with Allina Health employees in Minnesota and Wisconsin forming what's believed to be the largest group of unionized private-sector physicians in the U.S.²

More physicians than ever are now employees rather than independent operators,³ which means more physicians than ever are now eligible to join unions. With burnout levels high,⁴ many of those employed physicians may consider unionizing in the years to come if they believe it will improve their working conditions. Here's what family physicians should know if they're considering joining a union.

HISTORY

While unions have traditionally been more the domain of factory workers and government employees, physician unions are not entirely new. For example, there was a burst of physician unionization in the 1990s, in response to the expansion of managed care and health system mergers that created larger physician employers.⁵ Now, with health care organizations becoming still larger, doctors chafing under administrative demands and decreased autonomy, and ongoing disruptions related to COVID-19, there is again renewed interest in unionizing among the more than 70% of physicians who are employed.³ (Antitrust law largely bars self-employed physicians from unionizing to collectively bargain with payers. There are some exceptions, but this article focuses on employed physicians forming unions to collectively bargain with their employers.)

According to the American Medical Association (AMA), union membership among physicians has more than tripled since 1998, but unionized doctors still make up only about 7% of the total physician workforce.⁶

James Vandermeer, MD, is a recently retired family physician who helped form the Northwest Physicians Alliance (NWPA) union in Washington in the late 1990s. He said he thinks more primary care doctors should explore unionization as a way to improve their working conditions and patient care. But he cautioned that it's not an easy process.

Unionization often requires enlisting a local union organizer, building an organizing committee, getting a majority of your coworkers to sign union support cards, submitting those cards to the National Labor Relations Board, and then holding a vote — all before negotiating your first contract (if the unionization vote passes).

“I'm disappointed that there hasn't been more unionization of physicians,” Vandermeer said. “But having gone through it and seeing how difficult and tedious it is — like so many things that are terribly important can be — I'm not necessarily surprised.”

Matthew W. Hoffman, MD, is one of the physicians who organized the new union at Allina Health. He said he spent “thousands of hours” on it, but he believes it is already worth the effort because it has restored his optimism about his career and medicine in general.

“Many of us spent many, many hours doing it,” Hoffman said. “But for me, this was about my future and the future of primary care at Allina and in the country. The doctors need to have a say in what's going on in these big systems. They take care of so many patients.”

WHY PHYSICIANS UNIONIZE

Two subgroups of physicians are already broadly unionized in the United States: trainees and government employees. Medical interns and residents have their own division within the Service Employees International Union (SEIU), and doctors who work for government agencies, including the U.S. Department of Veterans Affairs (VA), are eligible to join the American Federation of Government Employees. (See “Examples of physician unions.”) Unionization has surged among interns and residents in particular since the beginning of the COVID-19 pandemic.^7,8 Some residents who joined unions have said it helped them push back against myriad concerns about their working conditions, including long hours, low pay, filthy call rooms, and even being deprioritized for COVID-19 vaccinations.⁹

Federal law limits what VA doctors can collectively bargain for, but they have used their union representation to argue for stronger whistleblower protections, as well as higher pay.¹⁰

Vandermeer's union, the NWPA, is no longer active. But Vandermeer said that when he was leading the union, it was able to hold the line on many issues related to working conditions and pay, because once the union was certified, management had to negotiate those changes rather than make them unilaterally. For example, the union was able to convince management to roll back some increases in relative-value-unit thresholds that were tied to physician pay and preserve support staff levels so that doctors weren't forced to take on administrative tasks such as finding and entering lab results in the EHR.

Other private-sector physician unions have successfully negotiated for their employers to contribute to “patient care funds” that union members can use for training, equipment, or other care needs they identify.¹¹ In 2023 alone, health care unions successfully negotiated pay raises, better staffing ratios, and opportunities for professional development.¹²

The Allina physicians said they were motivated to join the Doctors Council union (another division of SEIU) due to a general lack of control over the way they practice medicine and maintain the doctor-patient relationship.¹³ Some specific grievances included interference by insurance companies or other third parties, central booking of patient appointments that failed to maintain continuity of care, and a lack of transparency around administrative decision-making.

The union is still negotiating its first contract with management. Hoffman said it's too early to tell how effective it will be in changing the overall working environment, but it's already making some difference. He said that when Allina told its clinicians they would be moving to a new value-based payment model that would drastically change their schedules, the union was able to tell management that's something they would have to negotiate.

“I can't even explain how much of a sea change that is. That's something we never would have had the opportunity to do before,” Hoffman said. “Now we all have the opportunity to say, ‘We need to have a voice in designing what this looks like.’”

WHAT KEEPS DOCTORS FROM UNIONIZING

There are many concerns that have traditionally prevented doctors from unionizing. They include the following:

• Union activities taking up too much time, especially for residents who already work long hours,¹⁴

• Unions not being an effective solution to the problems causing physician burnout,¹⁵

• Patients losing trust in health care organizations if they perceive physicians and management to be adversaries,¹⁶

• Erosion of the doctor-patient relationship if patients perceive doctors are motivated by money,¹⁷

• Ethical concerns about the possibility of strikes harming patient care.¹⁸

It's somewhat difficult to evaluate the legitimacy of these fears, because little data exists on the impact of physician unions, especially in the U.S.

A pair of meta-analyses published in 2022 found that strikes by health care professionals disrupt health care delivery,¹⁹ but have no negative impact on mortality.²⁰ The meta-analyses included strikes by both doctors and nurses, most of which occurred outside the U.S.

There is some evidence that concerns over health care unions' effectiveness are legitimate. A 2021 study found that unionizing did not improve surgical residents' well-being,²¹ and in some cases, even when nurses' unions won concessions — such as more favorable staffing ratios — they struggled to enforce them.²²

Union negotiating power also may differ by state. All private-sector unions in the U.S. are governed at the federal level by the National Labor Relations Act (NLRA), but states have their own labor laws that may be more restrictive (e.g., “right-to-work” states prohibit employment contracts that require employees to join a union or pay dues). The effectiveness of health care unions may also be self-limited by their workers' reluctance to strike, which is the ultimate leverage unions have over employers. Vandermeer said physicians who belong to unions are careful in how they strike — they close their practice, but someone covers for them, so patients are cared for. Also, the National Labor Relations Board requires that unions give hospitals at least 10 days' notice before striking, so they can make arrangements to ensure patient care. Still, Vandermeer said physicians should only strike over issues of patient safety or working conditions.

“The strike is the final tool in our armamentarium,” he said. “But it is really only the threat of one that brings management to the table sometimes.”

Hoffman said a strike is a “last resort” and something he hopes will never happen, but the bigger threat to patient access right now is the current system that is burning out physicians.

“The whole goal is that we're making primary care a much more desirable job that people want to come into and stay in,” Hoffman said.

WHAT PHYSICIAN ORGANIZATIONS SAY

Tax-exempt physician groups, such as the American Academy of Family Physicians (AAFP) and the AMA, cannot collectively bargain on behalf of their members,²³ and historically have not endorsed or opposed unionization.

The AAFP has no official position on whether physicians should join labor unions. Stephanie Quinn, AAFP senior vice president of external affairs and practice experience, said the organization's various state chapters have a wide variety of views on the issue, and the national organization's focus at this time is to preserve and expand physicians' clinical autonomy regardless of whether they're in unions. The Academy's Congress of Delegates did ratify a statement in 2019 that says “The AAFP unequivocally supports the right of physicians to organize and bargain collectively.”²⁴ It was ratified under the heading “Collective Bargaining as an Integral Part of Single Payer,” but in July 2024 the AAFP's board of directors took out the reference to single payer and made it a broader statement that applies to collective bargaining generally. In September 2024, the Congress of Delegates adopted a resolution to have the AAFP commission a study of physician unions to be completed by mid-2026.²⁵

The AMA also supports physicians' rights to collectively bargain but urges them not to participate in strikes as a bargaining tactic or join “workplace alliances” with non-physicians who don't share physicians' ethical codes.⁶

The AMA once dabbled in unionization, founding a nonprofit collective bargaining organization in 1999 called Physicians for Responsible Negotiation, which expressly prohibited strikes. The AMA abandoned the effort five years later amid low membership.²⁶

The AMA in the past has also supported expanding physicians' rights to collectively bargain without joining a formal union (and paying union dues) and offers a webinar outlining the pros and cons of collective bargaining for physicians.²⁷ For example, under current law, any group of two or more doctors can designate a representative to collectively negotiate with their employer, and the NLRA protects them from retaliation for doing so, even if they're not in a union.

In theory, this could allow physicians more say over decisions that affect their working conditions while preserving a less adversarial relationship with management. In practice, however, exercising the NLRA's legal protections without the backing of a formal union (which typically has its own legal representation) can be onerous. For example, although courts have repeatedly ruled in favor of an autoworker who sued Tesla alleging the company illegally fired him for trying to organize a union, the worker has remained in litigation for five years as Tesla continues to appeal.²⁸

Vandermeer said bargaining without a union becomes a question of how much physicians trust their employers to negotiate in good faith. If you're in a union and you think they're not bargaining in good faith, you can file either a formal grievance or an unfair labor practices (ULP) charge. Both approaches have advantages and disadvantages, but without a union, you may only choose the latter.²⁹

WHAT'S A PHYSICIAN TO DO?

The decision to join a union is complex, and physicians must weigh factors that may vary dramatically, such as their state's labor laws, their relationship with management, their level of satisfaction with their working conditions, whether they're willing to spend time and money on union activities and dues, and their comfort level with negotiating a contract and potentially striking.

Physicians may also consider the pros and cons of other options, such as coordinating with colleagues to bargain collectively without a formal union, where allowed legally. As physician unionization grows, more data will hopefully become available about the effect unions have on physician well-being and patient outcomes. That may make these individual decisions easier.