I occasionally read Outside Counsel– Notes on a Glamor Profession, a stimulating weblog by a New York attorney. I noticed this there today:

I have written before on the topic of physicians unionizing, (scroll down to the second letter) but it seems to be a bad idea whose time has come. Doctors want to practice medicine, and they keep thinking that the way to do this is by giving away control of their profession. We have accountants deciding whether an MRI is necessary today because the docs liked the idea of HMOs (mostly because HMOs looked like a good way to universalize health insurance, maximizing the profitability of medical practice). Now they are in businesses, and they don’t like it. Quite right, too, since one of the hallmarks of being a “professional” is being independent. Unionizing amounts to conceding that they have lost control of their profession, however, and merely substitutes one group of nonprofessionals for another. I look at this, and I marvel that there are lawyers who favor multidisciplinary practice. Accountants are the natural enemies of independent professionals– and the group-think paradigm which unionization represents is likewise no way for a professional to operate. It is frustrating that the American health care system is so disfunctional that its doctors are starting to believe they are disenfranchised– where does that leave the patients?

From my perspective as a practicing physician, I agree that it would’ve been misguided if true, but it is a gross misrepresentation to claim that the profession has willingly given up its autonomy. The managed care approach to cost containment was externally imposed; the species of HMOs that dominates today comprises ‘products’ essentially generated by the health insurance industry, not MDs. I don’t think any physicians felt it would maximize profitability in comparison with fee-for-service paradigms, and by and large MDs employed by HMOs are salaried employees, making less, and under the gun with productivity demands, working harder, than their colleagues in other sectors of medical care. Business incentives are inherently incompatible with taking adequate care of patients, and physicians have always known it (except those ‘businessmen in white coats’ whose interest has always been entrepreneurial rather than patient-care-oriented!).

I agree, the impetus to unionization is an essential acknowledgement of a loss of autonomy, but the labor movement has always represented empowerment of exploited and alienated labor. If there is a problem with doctors unionizing, it is that it does not have any ‘bite’ without the threat of a strike, and I’m not sure a work stoppage is compatible with a service profession, not that my friends who are nurses agree. I also agree that we have to be concerned about the fate of patients in a healthcare system where physicians are disenfranchised. There are some indications that the public realizes they are getting a raw deal from the healthcare bean counters. For example, see this, from the Boston Globe, regarding the mental health sector.