Introduction

The quality of care that American healthcare workers provide has many new practical and theoretical challenges. These include persistent post-COVID-19 staffing issues, ongoing high turnover rates, and increasing rates of attrition in a field where the hiring process is costly and challenging.¹ Other employment-related causes of provider dissatisfaction also continue to accumulate. Over time, there has been a transition to Electronic Medical Records (EMR) for medical record keeping, which require an ever-increasing amount of mandatory education to understand their increasing complexity and continual updates. EMRs have also introduced inboxes that are often full of patient-care related matters that can follow providers home.² Dissolution of billing services has forced providers to complete their own billing, which requires an in-depth understanding of complex medical billing details and rules. Taken together, these pressures continue to mount on a workforce that is struggling with worker shortages and burnout.^3,4 Meanwhile, the individuals who remain in the system are in some ways powerless to say ‘no’ to additional tasks for fear of losing their employment.

To add fuel to the fire, hospital reimbursement rates have been diminishing,⁵ with additional reimbursement at risk when certain metrics—such as hospital acquired conditions⁶ or readmission rates⁷ —are not met. In conjunction, physicians have continued to see reductions in their reimbursement, as the Centers for Medicare and Medicaid Services (CMS) recently announced another decrease in 2025 reimbursement rates—part of a trend that has been ongoing since 1998.⁸ Meanwhile, the costs and overhead of providing healthcare have steadily increased, while healthcare systems have shifted toward a more corporate mentality with a greater focus on “the bottom line” rather than patient-centered care.⁹

Meanwhile, there has been an increased focus on mental health and work-life balance among healthcare employees, especially in newer generations of medical practitioners who have started trickling into the medical system and who place increasing importance on personal and mental well-being.¹⁰ Future generations of clinicians may be less inclined to provide more work with higher administrative burdens for lower rates of reimbursement. Nevertheless, overall corporate presence is expected to increase as the percentage of hospital-employed physicians, rather than those in private practice, continues to grow.¹¹ While participation in hospital systems is important for shaping and driving larger-scale change, hospital-employed physicians practicing in large and sometimes anonymous work environments might feel a loss of independence and autonomy, as goals regarding patient care and systemic change may not always align or easily co-exist.  

This combination of changes in payer/payment landscape and a generational shift in workforce mentality has driven healthcare employees to seek to become larger stakeholders in shaping how their care is delivered. Many providers also wish to have more bargaining power. As a result, there has been an increasing number of unionized physicians across the country, growing from 5.7% in 2014 to 7.2% in 2019, with a continued upward trend since then—including a recently reported annual rate of union petition filings of 23.3 between 2023 and 2024.^12,13

A Brief History of Healthcare Unions

Unions are not new to healthcare. The Wagner National Labor Relations Act (NLRA) of 1935 guaranteed the rights of unionization and labor strikes to all workers. Healthcare employees were not specifically exempted from this act, though physicians in private practice groups are not allowed to unionize due to anti-trust laws. Because physicians practicing in the United States have traditionally been employed in private practice, this has been a major impediment to unionization. Still, not long after the NLRA’s introduction, a strike was attempted in a hospital in Brooklyn in 1937, but a court injunction prohibited the union from striking.¹⁴ As a result of this attempt to strike, the American Federation of Labor removed the union charter and subsequently refused to sanction strikes in hospitals due to the potential harm to patients. In 1947, the Taft-Hartley Act was passed, which affected all not-for-profit hospitals (covering most hospitals at the time). This act mandated a 10-day written notice prior to striking at a healthcare institution, and also allowed for strike-breaking injunctions to be placed in the case of national health or safety concerns—in essence removing the possibility of strikes in most hospitals (although this was later amended under the 1974 Amendments). Given the essential nature of healthcare work, similar restrictions to physician strikes have been put in place in Belgium, Czech Republic, Hungary, Italy, and many other countries.¹⁵ However, while discouraged or unlawful in some countries, many others do allow striking, such as the primary care physician strike in France in October 2023.¹⁶

In-training (“trainee”, “house staff”) physician unions also date back to 1934. Strikes completed by housestaff unions include a four-day strike in 21 hospitals in New York and in three hospitals in Los Angeles in 1975, as well as an 18-day strike that occurred in Chicago despite the hospital obtaining a temporary restraining order. Following these events, the National Labor Relations Board ruled that physicians-in-training were students, and as such, had no status under the NLRA. In 1999, the Board ruled that medical residents should be deemed “junior professional associates” rather than students.¹⁷ Since then,  there has been an increased amount of unionization amongst residency and fellowship programs, with Penn Medicine, George Washington University, and Mass General Brigham house staff being recent examples.¹⁸ This increasing trend of unionization amongst trainees has also been accompanied by strikes: 150 residents at the Icahn School of Medicine at Mount Sinai went on strike in May 2023 and 800 residents and fellows at the University of Buffalo did so for 4 days in September 2024.¹⁶ The Committee of Interns and Residents, an affiliate of the Service Employees International Union, has seen a doubling of resident physicians and fellows over the past five years, from 18,000 members in 2020 to now more than 37,000 in 2025.¹⁹ Other countries have also seen trainee striking activity, such as the medical residents’ strike in the United Kingdom in January of 2024, and the South Korean medical residents’ strike—which was eventually joined by attending physicians and medical students—in February 2024.¹⁶

Practicing attending physician strikes date back to 1966, when the Doctors’ Association led a strike in New York City due to low wages. In response to additional unions forming in Nevada in 1972, the American Medical Association (AMA) enacted a new resolution in 1975 that allowed their organization to negotiate with hospitals on behalf of physicians. The AMA currently supports physician unionization, though it also recommends refraining from strikes as a bargaining tactic.²⁰ Despite this partnership with the AMA, attending physicians have recently garnered national attention by striking, such as during the emergency physician strike in Detroit in April 2024 aimed at addressing long patient wait times and low staffing levels.¹⁶ At present, several unions exist in the United States for practicing attending physicians. Some of these unions belong to larger organizations, which afford them more leverage and resources during negotiations. These include the Union of American Physicians and Dentists (UAPD), which is part of the American Federation of State, County and Municipal Employees (AFSCME), and the Doctors Council and the Council on Interns and Residents, which are both members of the Service Employees International Union (SEIU).

Why Unionize?

Physician unions allow for collective bargaining toward goals that aim to reduce burnout, advocate for patients, and attempt to regain physician autonomy. The conditions set forth in a collectively bargained contract dictate how a union will affect a particular aspect of the healthcare system.

Unions can negotiate for better work conditions through improved staffing levels, fewer work hours, or seeing fewer patients, all with the goal of aiding burnout and improving patient safety. They can also negotiate better benefits and protections, as well as fair compensation and work schedules, all of which help ensure financial stability and potentially job security by attempting to enforce fair provisions that protect against layoffs. Examples of effective collective bargaining can be seen in residency programs in which residents were able to secure improvements in benefits (such as parental leave following the birth of a child), working conditions, work hours, and mental demands.²¹ An example of successful collective bargaining in physician groups includes the Lake Superior Community Healthcare Center, where physicians were able to negotiate improved scheduling and meeting times.²²

Unions may have other unintended consequences, however. By standardizing salaries, the system may be underpaying overperformers and protecting underperformers. Specialized physicians who may not be considered in negotiated contracts may find it hard to negotiate individualized contracts. Because of unions’ support for their membership, employers will find it more difficult to terminate even someone who is underperforming or unequipped for the job, potentially placing patients at risk. A healthcare system’s efficiency and adaptability may be hindered by fixed staffing ratios or the inability to advance new measures or initiatives because of roadblocks posed by union bureaucracy. Unions may also potentially lead to higher healthcare costs that may ultimately be passed on to insurance companies and patients.

How Does Unionization Occur?

The process for unionization commences when labor representatives reach out to assess interest, or representatives from the interested group reach out to a labor group to express interest in unionization. The labor group then seeks to assess the degree of interest by requesting that employees within a specific group (physicians, nurses, residents, etc.) sign an Authorization Request (AR). This AR may state that if the union were to go through, that this person would become a member of the union; furthermore, if the union were to call a strike, this person would not cross the picket line, or else they might face financial penalties for the hours worked during a strike.²³

Once a pre-specified number of members of a group (e.g., one-third) has signed an AR, the labor union can request a formal vote. Certain members of the group, such as Medical Directors, may not be eligible to participate in the union. Alternatively, if the union has greater than 50% of the employee group who have signed authorization requests, the union can force the unionization without a vote. If a formal vote is called into effect, typically only the vote of people who vote in-person are counted (no absentee balloting allowed). If more than half of the vote supports unionization, then unionization proceeds.

Once the union goes into effect, all employees within the group (e.g., nurses, practicing physicians, etc.) are typically represented by the union in collective bargaining and will have to pay dues, whether they signed the AR or not.

The Ethics of Unionization

The most ethically challenging proposition for anyone considering joining a union is that a union’s primary bargaining chip is striking. When a strike in any industry occurs, the parent company faces financial consequences that may lead to further bargaining. The union in and of itself does not hold any other powers in the collective bargaining process, and hospitals are not forced to accede to any demands that the union makes on behalf of the people it represents. This makes the possibility of a strike a very real one, even if it is something that the AMA recommends refraining from. To this end, they further acknowledge that, “in rare circumstances... [striking] may be appropriate as a means of calling attention to needed changes in patient care.”²⁴

The consequences of a strike in the healthcare industry are unlike those in any other industry. For example, they may contribute to patient harm or frustration through cancellations of outpatient appointments and surgical procedures.²⁶ Hospitals facing a possible strike frequently postpone elective surgeries or may stop admitting patients and only provide emergency care, leading to delays in care across the healthcare system and limiting healthcare access for patients and families. Even if the hospital can secure emergency staffing, it is unlikely that this temporary staff will have the resources, know-how, or experience within the system to care for patients as effectively as the permanent employees of the hospital. It is important to note, though, that despite these inconveniences, there does not appear to be evidence of worse outcomes or direct harm to patients.²⁵

If the goal of bargaining is to improve patient safety, how can a strike—which could place patients in theoretical harm—be ethically acceptable? Is the harm to a few people a reasonable price to pay for the greater good? To many, including the general public and organizations such as the AMA and the American College of Physicians, a strike is an ethical violation of a physician’s responsibilities and Hippocratic Oath, and an abandonment of physicians’ implicit contract with society.^{27, 28}

Yet we must also consider the other side of the argument. Physicians have dedicated their lives to helping others, yet they feel overwhelmed, burnt-out, and powerless to effect change because of the aforementioned burdens placed on them by the system. Is it ethical for these systems to continue to push their healthcare workers to the point of leaving the system, in the hopes that those who remain can fill in any gaps, or that replacements might be able to be hired more cheaply?

Taken further, how ethical is the current way our healthcare systems operate? How ethical are private equity firms who purchase and become involved in the operation of hospitals with a clear bottom-line of creating for profit hospital systems, when there is evidence that private ownership has a negative impact on patient experience and may be driving hospital systems to insolvency?^{29, 30} How can insurance companies who have a duty to their clients (the people they insure) also have a fiduciary duty to their stockholders, with the promise of ever-increasing profits? How do we balance paying for the increasing cost of medical care while reducing the provision of unnecessary care?

Unfortunately, no easy solutions exist for these issues. Physicians who find solace in unions are at a point where they believe that a union is their only way of maintaining patient care, advocating for themselves, and potentially keeping themselves from leaving the healthcare industry altogether—an alternative we continue to see in spades.¹

At the local level, systems that have partnered with their physicians and other healthcare workers in designing their staffing and compensation models have performed better. An example of this is the Kaiser Permanente group in California, where a partnership between physicians and the organization allows for a culture of shared responsibility.³¹ Healthcare systems should engage their workers to determine best practice models, staffing models, and fair compensation and benefits. In turn, there is a responsibility to identify and prioritize changes that will improve work-life balance, while partnering with organizational leaders and accepting some responsibility for the ongoing success of the organization.

Overall, both hospital systems and healthcare workers alike need to remember the focus of the industry in which they opted to participate—their patients. Despite living in a profit-first society, all parties must remember that the patient comes first. This is best accomplished with a happy and productive workforce, working for a healthcare system that values care and quality over profit.

Enshrining a minimum-staffing level during strikes into law at the national level could help ensure patient safety and reassure physicians’ ethical concerns during a strike, while protecting physicians from complaints related to abandonment brought to state medical boards.

Likewise, healthcare insurance companies need to be held accountable and should not hold a fiduciary responsibility toward stockholders. Does that mean they should be removed from stock markets altogether? On one hand, this situation creates a major conflict of interest for insurance companies, but on the other hand, it may also contribute to driving innovation. Although a universal payer healthcare system is one potential alternative, it remains controversial, and an in-depth discussion of this proposed solution is outside the scope of this article.

Conclusion

Unionization rates amongst healthcare workers continue to increase throughout the United States and are driven by a combination of diminishing reimbursements, the loss of private medical groups, and an intergenerational divide on work-life balance. While strikes can be ethically problematic and potentially place patients at risk, they are driven by ethically questionable practices throughout the healthcare system. Potential solutions should focus on establishing and maintaining partnerships between hospitals and their employees to create a culture of shared responsibility.