Across the country, doctors who fear they have lost control of patient care to corporate accountants are turning to labor unions for leverage against hospitals, clinics and managed-care groups.
"This is not like you're talking to steelworkers or autoworkers who grew up with this," said Dr. Keith Shelman, who joined a union. "We look at this like it's our last chance."
Shelman was among 92 doctors at the Thomas-Davis Medical Centers in Tucson, Ariz., who voted to join an affiliate of the American Federation of State, County and Municipal Employees this winter.
"The major barrier to health care and our success as physicians is no longer the patients' illnesses but the system," said Shelman, who has practiced internal medicine for more than a decade.
As long as antitrust rules are not violated, managed-care organizations have no quarrel with unionized doctors, an industry spokesman said.
"Good patient care relies on good communication between physicians and HMOs. We're all working together in this," said Donald White, spokesman for the American Association of Health Plans, which represents more than 1,000 HMOs. "A process that furthers that communication will be helpful."
In recent months, podiatrists nationwide and physicians in New York also have voted to unionize, either directly or by affiliating through professional associations.
Inspired by the podiatrists and enthusiasm for unions among some of the 4,000 members of the Philadelphia County Medical Society, society president Dr. Raymond Lodise planned a regional meeting Thursday to discuss unionizing 16,000 medical society members in Pennsylvania and Delaware.
"The insurers have taken control of patient care, and we're trying to keep control," Lodise said. "We know that unions have tremendous influence with legislators, and we know that unions deal with people who are affected by managed care."
Other movements are afoot among neurosurgeons in Broward County, and more than 300 physicians in Oregon and in Albuquerque, N.M.
The doctors say the conflict at the heart of the debate is obvious: A physician's primary responsibility is to the patient, while a corporate executive is responsible for the bottom line.
Affiliation with the labor movement will allow some doctors to bring patient care issues _ restrictions on referrals to specialists, the amount of time allowed with a patient _ to the bargaining table when they negotiate contracts with health-care organizations.
"Money is not the issue," said Dr. Richard Osborne, another of the unionizing Arizona group. "The main thrust of your bargaining .
. is going to be altering working conditions, and that is going to directly affect patient care."
There may be a distinct financial advantage: Doctors allied with labor will have a leg up in marketing services to millions of members of other unions who like to buy union.
Doctors and union officials complain that the current system allows health-care corporations to operate with impunity. Many are exempt from antitrust laws. Some can claim immunity from malpractice suits under laws governing employee benefits.
"There are tremendous issues that need to be addressed in this whole health-care arena," Osborne said. "The public is not aware of most of them."
Osborne, an independent anesthesiologist who organized the Tucson doctors into the Federation of Physicians and Dentists, said individual doctors who agitate on behalf of their patients might find themselves out of managed-care contracts. Doctors hope that joining forces will give them a more effective voice.
"If you're going to provide a service, the patient who pays his premiums every month should not have to stand in line for care," Osborne said. Managed care makes money by doing just that, he said.
The National Labor Relations Board recognized the Thomas-Davis physicians' 92-23 vote to unionize. The parent company is fighting them in court.
In October, podiatrists from across the country formed a national guild and affiliated with the Office and Professional Employees International Union. Last month, 2,100 members of an independent practitioners association on Long Island also affiliated with OPEIU.
Doctors not employed by public hospitals or under a managed-care group must form physician associations before unionizing in order to avoid antitrust laws.