Healthcare Insights: A Blueprint for Physician Organization

For the last several years in my role at the Scheinman Institute I have had the opportunity to hear from physicians and physician organizations across the country.  The theme of the inquiries has been consistent: attending physicians state that corporate medicine has negatively impacted the core of physician practice:  the patient-physician relationship.

That universally stated complaint includes a consistent question from all these inquiries:  how can attending physicians organize to regain control of that relationship?  

State medical societies, the American Medical Association (AMA), and many other professional organizations of physicians are responding to member inquiries on this subject.  Some, like the AMA and others are attempting to build some internal capacity to be responsive through meetings and passing resolutions in support of physician organization.

In this emerging dynamic of physician inquiry about the need for collective action, the American College of Physicians (ACP) which is the largest medical specialty organization and the second-largest physician group in the United States, on April 29,2025 published among the most comprehensive papers devoted to physician organization to date, entitled, Empowering Physicians Through Collective Action: A Position Paper from the American College of Physicians.

In this edition of Healthcare Insights, I want to explore the issues identified in the paper which the ACP emphatically argues must be addressed through collective action. The issues are in most cases systemic problems which include, but go far beyond, day-to-day issues that physicians confront in terms of traditional subjects of concern related to wages, hours, working conditions, and conditions of employment.  The paper states:  “Physician-driven collective bargaining may be a way to regain influence over the systems of care on behalf of patients and balance the influence of consolidated health care behemoths that prioritize profit and efficiency over high-quality patient care. However, it must be approached with caution and sensitivity to prevent self-interest from overtaking the sacred nature of the patient–physician relationship. In 1999, Pellegrino and Relman argued against physician unions, noting that, “even those limited to fully salaried physicians, are, in essence, economic bargaining instruments for which the ultimate power is the threat of withholding services.”

The modern health care landscape demands a new form of physician organization, one dedicated to putting patients first, achieving whole-person care, and restoring the joy of medical practice. According to Eric Topol, “such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients. Its top priority might be restoring the human factor—the essence of medicine—which has slipped away, taking with it the patient-doctor relationship.” It is imperative that physician unions (and other medical organizations) act in the service of their patients, not their own interests. Notably, some professions with relatively high rates of union membership, like nurses, also have high levels of public trust.”

Traditional collective bargaining, especially for first contracts, tends to be a power struggle between the employer and the union over the desire by the employer to maintain their “inherent management rights” to manage the enterprise.  The employer views each and every demand by the union as an encroachment on what historically had been an exclusive right.  The result is a slow and acrimonious negotiation over this shifting balance of power.  

Moreover, U.S. labor law has a lengthy and complex canon of “common law” which interprets the difference between “mandatory” and “permissive” subjects of bargaining.  Mandatory subjects of bargaining include wages, hours, overtime, benefits, discipline, discharge, layoff, vacancy, health and safety and other such “terms and conditions” of employment.

So-called permissive subjects of bargaining include many issues that physicians and other healthcare workers regard as mandatory and essential, such as organizational strategy and decision-making which impact the conditions that determine how patient care is delivered. Such issues include how the health system plans its budgeting and staffing, or change hours and models of care delivery, let alone the almost daily impact of new technologies.  All of these foundational system issues have tremendous consequence on what the day-to-day care delivery environment is like.  It is in this area that the overwhelming majority of concerns exist among physicians.

When subject matter is determined to be permissive, labor law disallows bargaining to impasse or taking collective action in support of such subjects.  In far too many cases, the risk involved in acting in support of such issues often limits ultimate agreements in union contracts.  As such, real problem-solving or getting at root causes of issues can be extremely limited. 

Nonetheless, traditional collective bargaining has led to positive breakthroughs in many negotiations in healthcare:  many contracts have provisions to ensure safe staffing, allow frontline input into care delivery models, establish labor-management committees that support non-binding, but in-depth dialogue about important issues related to patient safety, operational improvement, employee safety and well-being, and many related topics.  Many health care contracts include commitments to workforce planning and development to avoid shortages of employees, and build systems for recruitment and retention.

But when it comes to decision-making about structural matters such as where and how work will be done, patient-staff ratios, time allotted for patient interaction, and most importantly maintenance of professional judgment in the hands of the physician, we know from experience that employers are largely unwilling to give ground but rather take strong stands to retain “sole decision-making authority” over such operational and business matters.  Many of these subjects are considered permissive subjects of bargaining, and it is almost universally common for employers to vigorously attempt to hold the line on these topics without giving up control.

For physicians especially, but for all healthcare workers, this framework is exceedingly frustrating and tends to promote increased acrimony and adversarialism.

In this time of increasing calls for collective action by physicians, how these central issues to physician concern about the current and future status of their profession are dealt with may determine the ultimate success of the need for collective action measured against results of such collective action.

Below are the specific recommended “calls to action” by the ACP. As you will see, these issues tend to be issues beyond the scope of traditional collective bargaining.  

“The primary objective of collective empowerment actions by physicians should be to ensure that patients have access to safe, affordable, high-quality care, and ACP supports using collective empowerment actions to improve quality of care, health equity, the patient–physician relationship, and physician well-being. ACP supports research into the effects of physician collective empowerment actions on patient care and physician well-being.

• Practicing physicians must be included in executive positions and have voting privileges on hospital and health system governing boards and other leadership bodies. Physicians must have a way, including through the organized medical staff, to meaningfully collaborate and communicate with hospital and health system leaders regarding patient care and safety, clinical policy, administrative decisions, and working conditions. ACP recommends that physician staff leadership include physicians-in-training.
• ACP supports the right of physicians to engage in protected concerted activity to amplify concerns about health and safety, working conditions, and other issues without retaliation or penalties from their employer. ACP recommends physicians explore public advocacy, organized protest, and other activities to improve patient care and physician well-being.
• ACP supports the right of physicians to engage in collective bargaining activities that improve patient care, the patient–physician relationship, and physician well-being.
• Physicians should be permitted to choose to join or not join a labor union or organization.
• Physicians should prioritize forming or joining bargaining units with other health care professionals dedicated to improving patient care and aligned with the principles of medical professionalism and ethics.

ACP supports legislative and other efforts to narrow the definition of “supervisor” for the purposes of collective bargaining. Frontline physicians should not be considered supervisors solely because they provide clinical leadership to a health care team.

• Stepwise actions, from refusal to perform administrative or billing duties to concerted refusals to work, should only be considered once all other negotiating tactics have been exhausted and efforts have been made by all involved parties to ensure safe patient care.
• ACP supports exploring innovative approaches to amplifying physician voice, including labor–management partnership and professional association–union “dual affiliation” models.
• ACP reaffirms that independently practicing physicians should have the right to negotiate jointly with health insurance plans over terms that affect the quality of, and access to, patient care, including payment and administrative policies that adversely affect access and quality.”

With all of the foregoing in mind:  that there is a growing consensus among physicians and their own organizations that physicians must engage in collective action as stated above: “The primary objective of collective empowerment actions by physicians should be to ensure that patients have access to safe, affordable, high-quality care, and ACP supports using collective empowerment actions to improve quality of care, health equity, the patient–physician relationship, and well-being”, a rare opportunity presents itself to advance a new theory of organizing for the nation’s physicians, in as much as it seems self-evident that traditional forms of organizing may be insufficient to meet the need and scope of the issues identified in this paper.

Based on the emerging consensus and possible actions needed to address a clear crisis in the medical profession which touches patients, policy and the physicians themselves, a theory of organization might include:

1. Physician organizations should unify their individual calls to action into one unified call to action that unsilo the dozens of analyses of the broken health care system that contributes to the erosion of care and medical practice.
2. Connect physicians across regions and geographies as opposed to traditional organizing one place of employment at a time.  In so doing, physicians can bring communities together around access and affordability.
3. Turn advocacy into action in recognition of the unrealized power physicians have to impact both public policy and employment-based policy which are inextricably linked to public and private reimbursement and regulations that determine the environment in which care is delivered, and how physicians’ practice is impacted in ways that are inconsistent with the sanctity of the patient-physician relationship.
4. Stand for the essential rebuilding of primary care, family practice medicine, and pediatric care which are the foundational needs for healthy communities everywhere.  Physician shortages abound in these specialties due to low salaries, onerous working conditions, and lack of integration and coordination of care.  
5. Stand for the affordability of medical education which is so costly that choosing the low paying specialties of primary care is an increasingly impossible choice for new doctors going into practice.
6. Construct regional collective bargaining with the participation of industry, government, and physician organization to incentive large scale problem-solving. 
7. Utilize collaborative approaches to collective bargaining as identified in the ACP paper; approaches well-known through major partnership efforts such as the labor-management partnership at Kaiser Permanente.
8. Create “standards boards” that have shown promise in other industries that support government oversight (usually at a municipal or regional or statewide level) of industry practices to benefit the community and the workforce. (example:  Fast Food Council: On September 28, 2023, Governor Gavin Newsom of California signed into law AB 1228, the Fast Food Restaurant Industry legislation that raised the hourly minimum wage rate for certain fast food workers to $20 effective April 1, 2024. In addition, the legislation established a Fast Food Council that  develops standards, rules, and regulations for the fast food industry.

Healthcare Insights will continue to monitor the growing activism among physicians and how their traditions of advocacy evolve to new forms of action and organization.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.