Cruess, Richard L. MD; Cruess, Sylvia R. MD
The well-documented changes in health care delivery, the complexity and effectiveness of modern health care, and the increased cost of health care services have transformed the practice of medicine from what once was termed a “cottage industry” to an activity that absorbs a significant percentage of the gross domestic product of every developed country.1 Increasingly, individual physicians are required to function in an environment in which either government or a highly competitive marketplace is dominant. In addition to producing physicians who are scientifically and technically competent, medical schools and training programs have an obligation to ensure that future practitioners understand the environment within which they must practice and the impact of this environment on the traditional values of the medical profession.2,3 This has gained importance as medicine's values, which have traditionally been encompassed by the term “professionalism,” are under threat, and there is a consensus that the nature of professionalism must evolve as society and medicine change. The “nostalgic professionalism” of the past is no longer appropriate.4 The professionalism that is taught and learned must simultaneously attempt to preserve medicine's core values while being relevant to the issues of the day, issues that include unionization and strikes.
The article by Li and colleagues5 addresses the controversial subject of strikes by physicians and health care professionals. The authors contend that medical schools must ensure that students and residents learn about the issue, reflect on it, and develop their own responses. However, this is but one aspect of the larger question of how medicine relates to the society it serves and how the profession organizes itself to negotiate both the broad aspects of this relationship and the details of working conditions and remuneration. These represent important aspects of medicine's social contract, which determines the nature of contemporary professionalism.2
Medicine's Position in Society
The lack of a national health plan in the United States has had many consequences, one of which relates to the organization of medicine and the roles of medicine's associations and institutions. In virtually every developed country, the acceptance of health care as a basic right has resulted in a change in the relationship between medicine, government, and the corporate sector.6 Well into the second half of the 20th century, medicine dominated both this relationship and the marketplace.1 As medicine's effectiveness increased, health care became essential to the well-being of citizens, and, because of its cost, individuals required protection from the financial risks involved in serious illness. In these same developed countries the structure and funding of health care were altered, with either government or a mix of government and the private sector attempting to diminish personal risk through various combinations of public delivery of care and/or insurance. During this process, medicine lost its dominant position in the system, with the state and/or the commercial sector as payers achieving dominance.
In countries with national health programs
In countries with national health programs, it was necessary to negotiate a change in the relationship between medicine and society, and structures were created to allow negotiations to take place. The basic requirement is a negotiating table with representatives who speak for medicine and representatives who speak for society.2 When there is a single-payer, or a mixed system in which the government pays for a majority of services, it is essential that the profession be well represented at this negotiating table. In most instances, existing medical associations, which traditionally have represented the profession, continued to speak for their constituents. Because of the nature of the issues and of the negotiations, many evolved to become unions or were formally designated as such. The British Medical Association is a legal union,7 and, in Canada, the provincial medical associations were transformed into unions or quasi-unions. In Europe, physicians' unions are the norm.8 Society is represented by government officials, and, thus, the nature and composition of the negotiating table and of the issues are clear to all.6
In the United States
As pointed out by Stevens,6 in the United States, “there has been no similar concentration of responsibility for universal health insurance at national, state, or local levels and no single government agency responsible for delegating formal power to medical organizations in relation to organized payment and service systems.” The result is a very decentralized system of negotiating, which generally takes place at a local level. Less than one-third of physicians in the United States, for example, belong to the American Medical Association (AMA), the organization that has the mandate to speak for the profession.6 The loyalty of most practitioners instead seems to be to their specialty associations, whose charges are restricted to their own disciplines. Thus, in the United States, there is not a centralized negotiating table at either the national or regional level, and it is difficult to say who represents medicine.
It is necessary to highlight two other issues. There are legal barriers to the unionization of physicians in the United States9 that have clearly inhibited attempts to organize medicine at the national level, although employed physicians do have that right. In addition, despite the fact that the AMA has recognized physicians' right to organize, there also is a strong feeling that unionization represents a threat to professional values and is therefore incompatible with the professional role.10
Considering Collective Actions by Physicians
This, then, is the context within which collective actions by physicians, including strikes, should be considered. Strikes are unlikely to occur in the absence of a bargaining table and some form of organization of physicians, which has jurisdiction over specific services in a defined geographic region. These conditions are the norm in virtually every country except the United States. Strikes or threats of strikes by physicians and other health care professionals are a reality in much of the world. In France, they occur frequently,11 and, recently, Germany has also experienced health care professionals' strikes.12 As the United States continues to grapple with the issue of health care reform, it seems reasonable to expect that there will be major efforts at cost control, attempts to shift tasks from physicians to other health care workers, more centralized control of payment methods, and more physicians becoming employees. Physicians have a legitimate right to defend both their professional status and their financial interests, and they must be well represented in negotiations over such issues. As this occurs, experience in other developed countries sends an unmistakable message: There will be pressure for physicians to take collective action, including going on strike. American medical students, residents, and indeed practitioners need to understand the issues, be prepared to make personal decisions, and be aware of the potential implications of their actions.
In the literature
There is a modest literature on the subject that can help to illuminate the issues. Several important points have been raised.
* There seems to be general acceptance of the fact that medicine does need representation in negotiating with government and private-sector groups. This is particularly true of residents who do not have the same level of fiduciary duty, are employees rather than independent practitioners, and historically have been vulnerable to exploitation.7,13
* Physicians differ from other workers in that “their (alleged or primary) goal is not the making of money or the obtaining of status, but rather to help the person to whom they have a fiduciary commitment.”14 This does limit their options and, when strikes occur, should dictate that some common strike actions, such as a complete withdrawal of services, are unacceptable.12
* Physicians provide an essential service whose withdrawal is capable of causing great hardship to those they serve, including potential loss of life. For this reason, there is a need for physicians to morally justify any decision for collective action.13
* The most effective moral justification occurs when the central issue of the strike relates to the quality of health care or to the doctor-patient relationship. When collective action is taken solely to further the interests of the profession or its members, strikes are probably not morally justifiable.7
* Collective action can consist of a group of activities, the most serious of which is a strike. Other actions can include the refusal to perform administrative duties or a partial withdrawal of services while continuing to participate in emergency care.15
* Although a strike involves action by a group, it is an individual who makes the decision to actually withdraw his or her services.16
In our experience
In addition to what the literature says, we conclude this commentary with some thoughts based on our personal experience. We are Canadian physicians with backgrounds in academic and administrative medicine, who live in a country with a single-payer system. We share most of the continent with the United States and have nearly identical undergraduate and postgraduate training programs. In our home province of Quebec, we have lived through an almost complete withdrawal of services with only emergencies receiving care, a withdrawal of services by individual specialties, resident strikes, and strikes by nurses and support staff. In addition, we have observed collective actions taken by the medical profession in other Canadian provinces. We have not withdrawn our services. We have always worked full-time in academic institutions with protected salaries, which has made our choices easier, but we have had colleagues who did not agree with our actions.
On the basis of our personal experience, we offer the following observations in hopes that they will be of assistance to students, residents, educational administrators, and practitioners.
* With very few exceptions, strikes or the threat of strikes deal with either physician remuneration or physicians' working conditions. In these circumstances, it is very unusual to be able to rationalize the withdrawal of physicians' services as being intended to improve patient care. When physicians strike, in our experience, it generally is to better their own situation.
* The moral and ethical dilemmas posed by strikes are very real. Even those physicians who withdraw their services do so at great personal cost. Strikes constitute an extraordinarily difficult and draining emotional experience for the physicians who experience them, whether they withdraw their services or continue to provide care.
* The collegial nature of the profession causes physicians to value their relationships with their students, residents, and colleagues. Strikes invariably divide the profession into those who support collective action and those who do not. These differences of opinion can lead to divided medical communities and ruptured personal relationships that can have a lasting impact on friendships, medical communities, and health care in general.
* An important motivating factor for those involved in strikes should be to preserve the collegial nature of medical communities. There are always lives to save, students to teach, and residents to work with after a strike. It is important that the health care and educational teams be able to survive the experience. Thus, showing respect for the opinions of others is important, particularly for those in administrative positions who must devise strategies so that patient care and teaching can continue.
* The public's perception of the medical profession during the course of a strike can be both negative and profound. The profession is generally regarded as being economically privileged and has difficulty in convincing both the media and the average citizen (including patients) that its cause is just. A strike in Ontario in 1986 over the right to bill more than the prescribed fee schedule received no public support, and the government held firm.17 It had a devastating impact on the reputation of the medical profession across the country. Essentially, the public's trust in the profession was diminished, as it came to doubt medicine's altruism.
* When the profession is regarded as being genuinely concerned with improving care for the public, the public will often be on its side. This is also true if the public feels that the medical profession is not being treated fairly. The fee schedule for family practitioners in New Brunswick in the late 1990s was well below the Canadian average. The profession convinced the public that this interfered with the recruitment and retention of family practitioners, who already were in short supply. The threat of a partial withdrawal of service resulted in a significant change in the fee schedule.
* A complete withdrawal of service is probably never feasible, and several Canadian provinces have enacted legislation requiring the maintenance of essential services or legislation banning strikes of any kind.
* An unfortunate result of the process of unionization is that negotiations can become extremely confrontational and often seem to be governed by customs and practices drawn from labor negotiations in the industrial sector. Most practicing physicians find this distasteful and often feel themselves powerless to alter the situation. Medical associations are frequently seen to be acting in ways that are not consistent with the ideals of professionalism, something that is detrimental to the reputation of the profession.
* Unionization and professionalism are not incompatible. Although the issue has not been addressed directly in the literature, there seems to be no evidence that physicians in countries where unionization is the norm are less professional than their colleagues in the United States.8 In our experience, this is certainly true. Although the threats to the professionalism of American physicians and the threats to the professionalism of Canadian physicians are slightly different,2,3 the core values of medicine seem to be as well maintained by unionized Canadian practitioners as they are by their non-unionized American counterparts.
Medicine's social contract, which describes its relationship with society, is not static, and it seems inevitable that this relationship one day will require structured negotiations in the United States. For these negotiations to occur in an orderly fashion, the medical profession must be represented and must develop methods of influencing the outcome of the negotiations. Strikes, which in much of the world represent one such method, invariably conflict with medicine's professional values. These issues are important to students, residents, practitioners, and medical educators because they have the potential to radically alter the public's perception of the medical profession. They deserve a significant place in the continuum of medical education so that students and residents can reflect on them in a safe environment, develop an understanding of the potential impact a strike can have on patients and the profession, and determine how they would act in such a situation and why they would act in that way.