It’s an exciting time: workers from vastly different sectors, from warehouse workers to Uber drivers to teachers to journalists, are walking out of work, going on strike, and unionizing. This rebellion is taking place across many different professions—and it’s reaching unexpected groups. Historically, physicians have been perceived as a bulwark of stodgy conservative types—as “rebellious as a church group.” But recently, even doctors have been on the march.
The catalyst for physicians seems to be less about low pay and precarious employment (as it is for most other industries) as it is about the corporatization of hospitals, the exasperation of keeping up with electronic health records, and a sense that, between surprise billing, hospital litigation, and rising prices, medical care has become a distinctly extractive process. For the last few decades, the profession has attempted to remain aloof from the scrum of politics. Doctors don’t really have unions: Instead, trade associations have traditionally provided the main interface between doctors’ interests and the outside world. Now, however, new efforts are changing this dynamic, as doctors begin to lobby directly on behalf of their own and their patients’ interests.
Historically, physicians have been represented by the American Medical Association, a powerful trade organization. The AMA gained dominance in 1910, when it helped fund the Flexner Report, a document intended to standardize medical education and professionalize physicians. Among other effects (including a recommendation to shut down five of the seven existing black medical colleges of the era), the Flexner Report essentially ensured the AMA would become the primary organizing body for newly professionalized (white) doctors.
Today, the AMA calls itself a physician organization that promotes science, medicine, and public health, but its efforts have been, as Paul Krugman wrote in 2009, “consistently nefarious.” It spends an average of $16,000,000 to $20,000,000 on lobbying every year, burning through the seventh highest amount of cash of the nearly 3,800 organizations that directly lobby across the United States.
The AMA closely controls the number of physicians in the United States to protect high physician salaries, even as the United States increasingly suffers from a physician shortage. It is also behind the RUC, a physician-led committee that chooses payment rates for medical services, meaning that powerful physicians get to vote on how much they are paid per procedure. (Yes, seriously!) In effect, the AMA further concentrates the dominance of top physicians: specifically, those who own large practices, manage parts of hospitals, and the surgeons and specialists at the top of the salary hierarchy.
Because it is so invested in increasing the power of physicians at the top, the AMA’s actions have often been at odds with the interests of patients. In the 1960s, for example, President Johnson was planning to sign the groundbreaking Medicare bill, providing insurance for those 65 and older. The AMA mobilized against the legislation, launching a plan called Operation Coffeecup. They hired the young actor Ronald Reagan to record a 10 minute LP describing Medicare as “socialized medicine,” asking doctors’ wives across the country to host coffee meetings with their friends where they would play the recording. One of the most successful marketing campaigns of all time—mostly in that it doomed us forever to the phrase “socialized medicine”—the AMA nonetheless failed to stop the eventual passage of Medicare.
In the 1990s, the AMA signed a product endorsement deal with Sunbeam, a home appliances brand, only to back out after public outrage. And as Dr. Eric Topol, a well-known cardiologist, author, and podcast host, has pointed out, the AMA is not the only physician organization to engage in corporate product endorsement. For example, in 2010 the American Academy of Family Physicians accepted a large donation from Coca Cola to provide consumer education on sweeteners and obesity. This action was met with derision among some family doctors; a few even publicly ripped up their AAFP membership cards.
Policy lobbying and corporate sponsorships have increased alienation between physician organizations and their member doctors, as has the rise of corporatized medicine. In 1982, Paul Starr, a professor of sociology and public affairs at Princeton, predicted contemporary estrangement of doctors from physician organizations. In his Pulitzer-winning book The Social Transformation of American Medicine, Starr noted the trend of hospitals led by non-physicians and found that “the profession is no longer steadfastly opposed to the growth of corporate medicine.” For a variety of factors, he believed that the following decades of American medicine would be marked by hospital growth and consolidation, and the consequent loss of physician autonomy.
Starr also believed that the corporatization of medicine would stratify the profession, leaving physicians to be classified into four categories: “owning, managing, employed, and independent.” Unless the AMA was willing to act as a union—which he believed unlikely: “since some of its members are likely to be the owners and managers of such organizations, the AMA will find it difficult to represent both sides in labor negotiations”—Starr did not think the AMA capable of continuing to represent American physicians.
He was extremely prescient. Since the 1990s, absent the protests of any organization claiming to represent the needs of physicians, hospitals consolidated under corporate leadership. Today, hospitals in 90 percent of metropolitan areas are highly concentrated. This decade, for the first time ever, physicians became more likely to be employed by someone than to own their own practices. Once employed by a hospital system, physicians may lose even more power over their labor; physician noncompetes—a clause in some physician contracts that ban the physician from working for or starting a competing practice—are increasingly common. Similar to adjunct professors, the workers at the World Health Organization, and accountants, physicians now find themselves subject to the demands of consultants and administrators.
The impact of this corporatization on physicians has been decidedly negative. Physician burnout is rising—in 2018, nearly 80 percent of physicians reported feeling at least occasional burnout—and its prevalence has been linked to physicians’ loss of control over their work. In a 2015 article, Mayo Clinic Proceedings named lack of autonomy as one of the three key factors behind physician burnout. It compared the modern practice of medicine to a “fixing-people production line,” such that a physician friend of one of the authors confided that his schedule was so tight, he had no time for unscheduled bathroom breaks.
Meanwhile, despite technological and medical advances over recent decades, the working life of many modern physicians has become worse. Electronic health record software, attuned to the nuances of billing rather than good patient care, is nowhere near user-optimized. As it is, the software requires as many as 4,000 clicks during a single shift, and can be actively dangerous to patients. Meanwhile, patient visits are shorter, with some doctors expected to see patients every 10-15 minutes. And strikingly, the physician suicide rate is now the highest of any profession, with approximately one doctor a day committing suicide somewhere in the United States.
And, as Starr predicted, the AMA is divided between physicians who are owners and managers, and physicians who are employed, leaving the AMA to focus on maintaining physician salaries and blocking health care legislation rather than seeking structural change. For all these reasons, the winds of labor unrest are now blowing strongly through a large segment of the profession, as doctors begin to speak out about the impossibility of laboring under both the administrator class and badly-designed electronic records systems.
In November 2018, there was a public breaking point. Following a mass shooting, the NRA tweeted out that doctors should “stay in their lane” on the topic of gun violence. With the AMA silent, doctors themselves responded with vehemence. The hashtag #ThisIsMyLane trended as physicians shared their stories of just how closely gun violence is enmeshed in medical care. The flood of tweets represented doctors expressing their political opinions directly and en masse for perhaps the first time in American history.
Suddenly, physicians’ political voices were unleashed. A series of recent op-eds have called for physicians to push back on the NRA as a public health issue, and also to pay attention to the struggles doctors face at work. There have been calls for physicians to organize, to regulate, and to take back power from the concentrated forces of trade associations and hospital administrators that are squeezing time and money out of doctors and patients.
Topol, the cardiologist and podcaster, is behind much of the discussion. In his 2019 book Deep Medicine, he repeatedly asked physicians to consider what they want the future of medicine to look like. For example, the future of A.I. in the exam room has the potential to offload routine administrative tasks, giving physicians more time with their patients and less time staring at a screen. But, Topol notes, corporate hospital administrators would be inclined to turn time savings into more patient visits, rather than allowing each doctor more time with each patient. In an extremely popular New Yorker article this year, entitled “Why Doctors Should Organize,” Topol called on physicians to take up the mantle of the labor movement.
Topol may have started the recent discussion, but Dr. Danielle Ofri—a physician-writer and the editor of the medical humanities publication Bellevue Literary Review—has pushed it further. On a recent episode of Medicine and the Machine, the podcast that Topol co-hosts with fellow Stanford physician Abraham Verghese, Ofri called for a full-on physician strike. She proposed a day where physicians and patients alike refuse to fill out any kind of paperwork. While this may sound like a mild form of rebellion, by the standards of the medical profession this suggestion is shockingly radical.
Hospital administrators have not failed to notice the dissatisfaction of their physicians. But proposed solutions have fallen far short of structural change. Perhaps akin to Amazon playing pump-up music for their warehouse workers before they embark on a 10-hour shift with no bathroom breaks, hospital administrators have frequently called for “self-care” to prevent physician burnout. One of Ofri’s favorite responses to this is: “I don’t need Pilates, I need an assistant.”
But as more physicians seek to usurp their “human overlords” (as, during a recent phone conversation, Topol repeatedly referred to hospital administrators), it is worth asking if the outcome will be more favorable to patients. Doctors are in a unique position, similar to teachers, with vulnerable people directly reliant on their care. How these groups demand change without compromising their dependents may make or break the nascent physicians’ movement.
The recent Chicago Teachers’ Strike is an illustrative example of how effective organizing can balance these concerns. The striking teachers asked for better salaries, but they also demanded a nurse and counselor in each school, resources for homeless students, and smaller class sizes among other things. The union was so committed to the wellbeing of Chicago’s students that it continued to strike even after the mayor offered an updated salary package. As the Nation put it, the teachers “made ‘bargaining for the common good’ into a strategy to be studied.” It seems that the physicians’ movement has been learning.
In phone conversations, both Topol and Ofri told me that raising physicians’ salaries should not be a primary goal of organizing. They both acknowledged the reality of salary disparities among physician specialties, but also noted that few doctors are actively struggling to make ends meet. For example, Ofri, an internist at the public Bellevue Hospital, is probably poorly compensated compared to other physicians. According to Glassdoor, the average salary for a public New York City primary care physician is $162,000, compared to $211,000 for primary care physicians in New York City generally, which is still far lower than the average salary of $482,000 for orthopedists nationally. Despite this difference, Ofri said she is far more interested in improving doctors’ working lives and quality of patient care than getting caught up in questions of salary.
The stated goal of the physicians’ movement, insofar as it currently exists, is to improve patient care. By making demands centered around patients—more time for each visit, more scribes to take care of electronic health records, shorter working hours for residents, and so on—the movement hopes to win better care and simultaneously improve physicians’ working conditions.
Recently, some new physician-led organizations have cropped up. Progressive Doctors, a group that operates primarily on Twitter and Facebook, lets physicians know when progressive protests or petitions need assistance. Physicians for a National Health Program supports single-payer health care. A recent Time article noted the rise of a “new generation of activist doctors” mobilized around Medicare for All. Physicians in general have flipped to being majority-Democrat, after decades of being dominated by Republicans, as they seek new solutions to their problems (although, generally speaking, the highest-earning physician specialties remain oriented to the right).
Bigger structural changes may also be around the corner as doctors become more outspoken. Topol is part of a steering committee overseeing a new patient-centered, physician-led organization called Osler’s Alliance, focused on taking back power from the medical establishment. The nonprofit aims to “challenge the traditional professional society model by design” through organizing a critical mass of American doctors, although it remains to be seen if it is successful.
Of course, not all physician organizing will result in a positive outcome. This year, private equity-backed physician groups organized to kill bipartisan surprise billing reform, undoubtedly a blow to patients. And given that physicians operate within a much larger, complex medical system, it is unclear how much a doctors’ movement can accomplish. Doctors spending more time with each patient, for example, is better for the patient. But it might mean that specialist appointments are even more difficult to snag. And given the AMA’s control over how many physicians are trained and licensed yearly, the physician labor market is unlikely to open up anytime soon. Despite this, the AMA’s power largely exists in its membership: If a new organization can successfully siphon off a majority of physicians, it may have a real chance at structural change.
Regardless, the situation that currently exists is untenable. As the administrative class continues to push its physicians harder, doctors are increasingly pushing back. And with the focus on patient care first, the physicians might be able to emulate the Chicago Teachers’ Strike’s success. Undoubtedly, our medical system is broken. It’s time for more people within it to start protesting, including the physicians.