Unionizing The E.R.

With a thriving OB-GYN practice in Dallas, Dr. Robert Gunby never expected to complain about his working conditions. But then he never expected that managed care would transform his life. Gunby's salary has dropped 10% in the past four years, and he's had to dip into his personal savings just to pay his staff. And while he's used to nights spent in the delivery room, he says his workweek now clocks in at nearly 100 hours--up to 20 of them, he estimates, spent haggling with insurance companies over approval for drugs and treatments for his patients. "I used to take time off, but now I work all my waking hours," laments Gunby. "I'm just being gobbled up, and I feel as if I have no power."

So Gunby brought his gripes to the attention of the Texas state legislature and then aired them before the American Medical Association. Last week, at its annual meeting, the organization representing 290,000 doctors in the U.S. voted to try to bring Gunby and his colleagues some relief in an unprecedented way: by forming a labor union.

The image of a union card hanging next to a doctor's medical-school diploma may be difficult to envision. But frustrated physicians are increasingly turning to unions. The ranks of unionized doctors have grown 80% in the past three years, to about 40,000, or 6% of doctors in the U.S. And with health-care reforms like the Patients' Bill of Rights embattled in Congress, unions are being hailed as an elixir for consumers. Supporters of the movement contend that by banding together to negotiate contracts, doctors can better argue for coverage of such things as drug prescriptions and access to specialists. Says the A.M.A.'s board chair Randolph Smoak: "This is designed to benefit our frustrated patients."

Executives in the insurance industry, however, charge that doctors' motives are less altruistic. They say doctors, who by the A.M.A.'s own calculation have a median annual income of $164,000, are trying to pad their already cushy salaries. And they argue that the doctors' bold stand could wind up hurting their patients. According to a June report released by the Health Insurance Association of America, collective bargaining by doctors for higher fees could cause health-care premiums to balloon as much as 11%, adding up to $80 billion annually to the cost of health care in the U.S.

Then there are the potential legal hurdles. Federal labor laws designed to combat price fixing bar self-employed physicians, the vast majority of doctors in the U.S., from jointly discussing fees and contracts. Only 1 in 7 physicians--those directly employed by entities like hospitals, HMOs or state health departments--can currently unionize. In the past, doctors' groups that have tried to organize anyway have been slapped with antitrust complaints by the Justice Department.

Efforts are under way to change that. Last week Texas Governor George W. Bush signed a law to exempt physicians from such antitrust regulations. Republican Congressman Tom Campbell of California and Democrat John Conyers of Michigan have introduced a bill that would do the same nationwide. The bill, vigorously endorsed by the A.M.A., has bipartisan congressional support, but last week officials from the Justice Department and the Federal Trade Commission testified that it could pump up premiums.

Even if unions are deemed legal, many doctors question whether organizing is necessary--or ethical. "We're in a group that makes in the top 1% in income, and I'm not sure we need that kind of protection," argues Fred Campbell, a San Antonio, Texas, internist. Even more troubling is the image of doctors jeopardizing their patients by going on strike. On those grounds, Albert Yellin, a Los Angeles vascular surgeon, opposed the unionization last month of 800 Los Angeles County physicians. "Using our patients as hostages to gain things within our own self-interest is anathema to our whole mission," he says.

To quell worries like this, the A.M.A. has pre-emptively renounced its right to strike. It is even shying away from using the word union, preferring the squishier "national negotiating organization." The group says it will rely on tamer job actions like "slowing a bit on completing paperwork" required by HMOs. Yet representatives of other doctors' unions, such as the Union of American Physicians and Dentists, claim the A.M.A. is making a mistake by voluntarily giving up its most important bargaining tool.

Supporters hope the mere threat of joint action will coax HMOs to the bargaining table. It has already perked up frustrated doctors like Gunby. "They may kick me out of their plans," he vows, "but I'll go down fighting." So, no doubt, will managed care.