The physicians of Medalia HealthCare, in 46 clinics throughout Washington's Puget Sound, voted last year to unionize. We did so for the same reasons that many groups of intelligent, highly skilled and highly trained people (like pilots, nurses or engineers) might organize: to have a voice in the decisions that determine the nature of our working lives.

The environment

Just a few years ago, most of us would have found absurd the idea that physicians out of residency would need to organize to influence their working conditions. Most physicians didn't work in large groups, and those who did more often were partners and colleagues than employees. Catered to and sought after in recent years for our skills in cost-effective care management, primary care physicians were even thought to have a protected and privileged place; our income and prestige were rising even as our colleagues in other specialties lost ground — and sometimes lost jobs.

Now things have changed and are continuing to change, for us at Medalia and for many other physicians across the nation. Newly trained primary care doctors with increasing educational debt are seeing less of a future in solo or small-group practice arrangements requiring big buy-ins. Many readily sign on as employees in organizations that appear to offer security, more predictable hours, improved health and retirement benefits, and intangibles like a stronger identity in the community. Existing solo, small and not-so-small groups are willingly (or fearfully) being snatched up by hospitals and other health care organizations eager to set up outposts in new territory and secure market share. The problems arise when the cold realities of limited resources and unlimited patient demand collide with the hot-air promise of cost savings in managed care. Then the economic storms rain down on patients, physicians and payers alike. Free-falling fee-for-service payments and squeezed capitation rates increase the pressures on employed physicians to cut costs. In too many instances, corners are cut as well. Staffing and staff training requirements are reduced; the quantity and quality of equipment and supplies decline. Ever-greater numbers of encounters and patient-contact hours are set as “benchmarks” or “thresholds” while dehospitalization trends put sicker and sicker patients into tighter time slots. What little information is shared with providers about costs, charges and collections too often is unexplained (or, more troubling, inexplicable). Frequently changing compensation formulas have an inexorably downward trend, and many are too complicated for even their designers to explain, especially since the data to perform the required calculations often isn't available.

In this environment, employed doctors begin asking questions like, “How could our group go from being profitable, with charges in the 75th percentile and a 90 percent collection rate, into the red just six months after we joined the organization?” Too often, the answers are along the lines of “It's business; you wouldn't understand” or “None of the other docs are complaining, and things are the same for them” or “Just see more patients.” Often, no answers come at all.

The Medalia experience

While not all of this happened at Medalia, enough did happen to make us concerned that more was coming. Many organizations in and out of medicine experience similar upheavals. But for us, the upheavals damaged our ability to provide our best to patients.

Our physicians were simultaneously told to see more patients and informed that staff numbers and work hours would be cut. Physicians did work harder, and their duties expanded to include prepping patients, cleaning and stocking rooms, pulling and filing charts, and filing lab reports — all of which took time away from patient care. When copier paper and supplies, paper clips, business cards, practice brochures and chart forms came to be in short supply or unavailable, the work-arounds took more time, effort and thought away from patients — who already were frustrated by being unable to get through on the new, more expensive telephone system and by having appointments lost on the new, more expensive computer system. When long delays, lost messages and missing charts also became commonplace, patients weren't getting what they deserve: our very best. This was why we organized.

In the fall of 1997, employed doctors from Medalia clinics large and small met and solicited information from medical organizations, health care attorneys and unions. We wanted to know how to get our employer to communicate fully and share control over decisions that affected our work, such as recruiting new doctors, changing physicians' fees, setting requirements for patient contact hours and determining compensation. Short of litigating item by item, with all the attendant cost, uncertainty and delay, we could identify only one mechanism that would compel our management to provide the information we needed and give us the right to negotiate a legally binding contract: organizing as a labor union.

We formed the Northwest Physicians' Alliance and chose the United Salaried Physicians and Dentists (an autonomous physicians' union affiliated with the Service Employees International Union, the nation's largest union of health care workers) to represent and support us. Over seven months, we contacted all physicians not in the management structure, informed them of the unionization effort, obtained consensus on issues of concern and petitioned the National Labor Relations Board (NLRB) for the right to organize.

During this time, Medalia was continuing to reorganize. Practices were closed, and dozens of physicians were so discouraged by the administration's inflexibility that they left Medalia. At the same time, the health system spent hours of effort and at least $150,000 in legal fees — which would have been more appropriately spent on patient care — to fight our organizing efforts. Our administration argued that every physician was a supervisor and a manager and therefore not legally entitled to organize. This forced seven weeks of hearings before the NLRB. Nevertheless, in late April 1998, the NLRB issued a decision and order of election in favor of our petition to allow a vote.

We spent the next month campaigning; and in early June, Medalia physicians voted 104 to 75 to form a union. Just deciding to do something about our situation had brought us together in ways and numbers that had never happened before at Medalia. Deciding what to do has brought us even closer.

Editor's note: In an upcoming issue, Dr. Vandermeer will describe what Medalia's physicians hope to accomplish by organizing and will offer suggestions to help other doctors evaluate whether unionization might be an option for them.