Developing Personal Values: Trainees' Attitudes Toward Strikes by Health Care Providers
Li, Su-Ting T. MD, MPH; Srinivasan, Malathi MD; Der-Martirosian, Claudia PhD; Kravitz, Richard L. MD, MSPH; Wilkes, Michael S. MD, PhD
Dr. Li is assistant professor, vice chair of education, and pediatric program director, Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento, California.
Dr. Srinivasan is associate professor, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, California.
Dr. Der-Martirosian is senior statistician, University of California, Davis, School of Medicine, Sacramento, California.
Dr. Kravitz is professor and co-vice chair, Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, California.
Dr. Wilkes is professor, Office of the Dean and Department of Internal Medicine, University of California, Davis, School of Medicine, Sacramento, California.
Editor's Note: A commentary on this article appears on page 548.
Correspondence should be addressed to Dr. Li, 2516 Stockton Blvd., Sacramento, CA 95817; telephone: (916) 734-2428; fax: (916) 734-0342; e-mail: firstname.lastname@example.org.
First published online March 23, 2011
Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A45.
Worldwide, health care providers use strikes and job actions to influence policy. For health care providers, especially physicians, strikes create an ethical tension between an obligation to care for current patients (e.g., to provide care and avoid abandonment) and an obligation to better care for future patients by seeking system improvements (e.g., improvements in safety, to access, and in the composition and strength of the health care workforce). This tension is further intensified when the potential benefit of a strike involves professional self-interest and the potential risk involves patient harm or death. By definition, trainees are still forming their professional identities and values, including their opinions on fair wages, health policy, employee benefits, professionalism, and strikes. In this article, the authors explore these ethical tensions, beginning with a discussion of reactions to a potential 2005 nursing strike at the University of California, Davis, Medical Center. The authors then propose a conceptual model describing factors that may influence health care providers' decisions to strike (including personal ethics, personal agency, and strike-related context). In particular, the authors explore the relationship between training level and attitudes toward taking a job action, such as going on strike. Because trainees' attitudes toward strikes continue to evolve during training, the authors maintain that open discussion around the ethics of health care professionals' strikes and other methods of conflict resolution should be included in medical education to enhance professionalism and systems-based practice training. The authors include sample case vignettes to help initiate these important discussions.
Both within and outside of the health care sector, unions have effectively used strikes and job actions as contract negotiation tactics.1 Although strikes in the U.S. health care sector are uncommon, internationally, they have been a powerful tool for social change.2–6 Health care strikes create an ethical tension between an obligation to provide excellent care to current patients by not abandoning them during the strike and an obligation to advocate improving care for future patients by focusing on issues such as staff shortages, poor equipment, and closed facilities that might go unaddressed without social action. This tension is further intensified when the potential benefits of the strike include the self-interest of health professionals (such as improved salary, benefits, or work hours) and the risk is potential patient harm or death.5,7–9
Also, over the past 30 years, an increasingly large percentage of U.S. physicians have moved from being self-employed to being employees of organizations.10 As physicians are replaced by nonphysicians as clinic managers or hospital directors, they experience diminished control over their jobs with a loss in practice-related autonomy.11 Physician–employees need to negotiate their salaries and are evaluated based on issues such as productivity, adherence to practice guidelines, and patient satisfaction. Increasingly, physicians feel burdened and unable to advocate on behalf of their patients or themselves.11
In addition, a fundamental part of the medical training process is socialization into the culture and practice of medicine. During this process, students form their professional identities and values, including opinions on employment issues, conflict resolution, and patient advocacy. Compared with medical students, postgraduate trainees (residents and fellows) are in a unique position because they hold roles as both employees and students. In this article, we explore the ethical tensions posed by health care professionals' strikes, beginning with a discussion of the reaction to a potential nursing strike at our institution, the University of California (UC), Davis, Medical Center. We then propose a model for considering the ethical issues that may cause health care professionals' strikes, such as personal ethics, views on personal agency, and the strike-related context. Finally, we suggest that ethical discussions around job actions, advocacy, conflict resolution, and systems change be included as a crucial part of teaching professionalism and systems-based practice in medical education.
Experience at the UC Davis Medical Center
We became interested in the topic of health care professionals' strikes as medical educators after witnessing the responses at our institution to an impending nursing strike. In 2005, a group of 9,000 nurses at five UC teaching hospitals planned a one-day strike over wages, retirement benefits, and patient–staffing ratios.12–14 To plan for the strike, all UC health systems began decreasing inpatient census for a week prior to the proposed strike date, including canceling surgeries and diverting critically ill patients or patients with high-risk pregnancies to other hospitals. At our institution, medical students were asked to “become a nurse for a day,” whereas residents and attending physicians were asked to assume nursing roles in addition to their normal responsibilities. Some medical students supported the nursing strike and refused to cross the picket lines, let alone assume additional nursing responsibilities. Others felt that patient care should come first, that health care professionals' strikes were unethical, and that it was their duty to provide care if others were to strike. To better understand these disparate viewpoints, we surveyed medical students, residents, and attending physicians about health care professionals' strikes. Our study was deemed exempt by the UC Davis institutional review board. A total of 70 of 89 (79%) medical students responded, and 239 of 785 (30%) residents and faculty responded.
In the context of the impending strike, we found that attitudes toward health care professionals' strikes differed based on level of training (see Table 1). Our third-year medical students were more likely to believe that strikes are sometimes necessary to achieve important goals (61 of 69; 88%) compared with residents/fellows (46 of 67; 69%) and attending physicians (46 of 106; 43%; P < .01). Our medical students were less likely to believe health care professionals' strikes were unethical (14 of 69; 20% versus 23 of 67; 34% versus 56 of 106; 53%; P < .001) or to state that they would never strike (16 of 69; 23% versus 28 of 67; 42% versus 70 of 106; 66%; P < .001). Although the majority of medical students and physicians agreed that “patient well-being takes precedence over all other professional issues” (52 of 69; 75% versus 46 of 67; 69% versus 85 of 106; 80%; P = .47), medical students were less likely to feel that their obligation was to take care of their sick patients when other health care professionals strike (61 of 69; 88% versus 65 of 67; 97% versus 106 of 106; 100%; P < .01).
Our findings are consistent with those of the few other studies published on this topic, although most previous studies are from other countries with very different cultures. A survey of Croatian medical students during a physician strike found that most medical students felt that physicians should be allowed to strike (85%).15 Similarly, almost all Israeli medical students surveyed during a physician strike felt that physicians should be allowed to strike (97%).16
A last-minute state judicial decree stopped the 2005 UC nursing strike. However, the impending strike made us better appreciate that attitudes toward health care professionals' strikes are not homogenous and that medical education largely neglects discussion of this important topic.17–19
Ethical Tensions Posed by Health Care Professionals' Strikes
Professionalism is at the core of medicine's contract with society. According to the widely accepted international physician Charter for Medical Professionalism, the three guiding principles of medical professionalism are primacy of patients' welfare, patient autonomy, and social justice.20,21 The first two principles center on individual patient–physician interactions. The third principle, the principle of social justice, promotes a larger view of medical professionalism, which extends responsibility beyond individual interactions to an obligation to promote the community's health. This obligation would include addressing equitable distribution of health care resources, patient access to health care, and planning for recruitment and retention of health care providers. The ethical debate regarding strikes often revolves around tensions between promoting the individual patient's welfare and social justice.
Some physicians believe that primacy of individual patient well-being is absolute and that anything that jeopardizes this well-being is unprofessional. These physicians feel that all strikes pose a threat to patient well-being, and therefore all strikes are unethical.2,7,22 Other physicians feel that the primacy of patients' welfare is relative and that concern should focus on the greater good. For them, strikes are justified when present conditions jeopardize long-term patients' welfare (i.e., when patient safety issues arise from insufficient resources or personnel), poor working conditions negatively affect patient care (e.g., physician fatigue), or poor workplace environment jeopardizes staff morale, recruitment, or retention (e.g., compensation and benefits). Perhaps, as this latter group posits, some suboptimal health care systems might be unwilling to change without significant coercion.
There is a well-established societal precedent for sacrificing present needs for future needs in health care. Medical education itself is an example of such a sacrifice. Health care outcomes are better when experienced physicians perform procedures.23–25 However, society has determined that allowing inexperienced medical learners to work with ill patients (with varying degrees of supervision) has the societal benefit of preparing the next generation to become experienced physicians.26 Similarly, is there a legitimate ethical justification to sacrifice the needs of present patients for future patients in a strike?
Some sociologists would contend that self-interest, not altruism, has historically governed the actions of the medical profession.27,28 Freidson27 suggests that physicians are autonomous and self-regulating, and maintain their special status in society because they claim to be the most reliable authority on their profession with the knowledge, skills, and ethics to police themselves. He and others also suggest that at times physicians may use their special status in society to promote their own self-interests under the guise of altruism (e.g., reporting that the reason to strike was to improve patient care rather than to improve their own compensation).28,29 Although we did not find this to be the case in our survey, this issue should be directly addressed in discussions about health care professionals' strikes and job actions.
A Model of the Factors Contributing to Health Care Professionals' Strikes
We propose a model of the factors contributing to health care professionals' strikes for which the decision to strike may be influenced by personal ethics, views on personal agency, and other contextual issues (see Figure 1 for a diagram of this model). We propose this model through the lens of medical training, to provide a framework for educators as they expand their systems-based and professionalism curricula to meet the evolving needs of their learners. Our model integrates concepts highlighted by prior research in industrial and health care job actions and well-established behavioral change models. It is informed by literature on the reasons for striking in health care,5 theoretical models of conflict resolution,30 self-efficacy,31 civic volunteerism,32 planned behavior,33 and reasons for participation in political,34 illegitimate,35 and entrepreneurial36 activities. In the paragraphs that follow, we describe the elements of this model.
Influence of training level.
As previously discussed, personal ethics may vary with beliefs about patient primacy4,37 and social justice—perhaps influenced by learner level and other factors. A study surveying psychiatry residents found that they were more likely to cross the picket line and assume additional patient care responsibilities when they imagined themselves in the position of an attending, with a greater personal stake in the welfare of their own patients.38 If indeed residents are less likely to support striking if patients would be harmed,4 then trainees may feel empowered to support strikes knowing that an attending physician will provide care to the patients in their absence. This idea is supported by data showing that patient-related adverse consequences have not occurred during resident strikes or slowdowns. In fact, during an Israeli physicians' strike, the population-based mortality decreased, which may be a result of attending physicians' providing care to patients when the residents were not present.39 In addition, the degree of “ownership” for patients might influence strike viewpoints by trainees and physicians. Most students have not had to personally deal with the consequences of harm to patients. Therefore, compared with medical students, physicians may weight current patient well-being over that of future patients, perhaps because of their greater personal responsibility toward their own patients.
Influence of age or generation.
Age or generational differences seem less likely to account for the continuum of strike-related attitudes found between students, residents, and faculty. A study of Canadian physicians found no age/generational differences in physicians who chose to strike and those who chose not to strike.3 Further, research suggests that there has been little change in attending physicians' attitudes toward strikes in 30 years. In 1977, a year after New York residents went on strike to protest unreasonably long work hours, a survey of New York medical students and alumni from Albert Einstein College of Medicine found that fourth-year medical students (63%) and residents (67%) were more likely to believe that physicians should be allowed to strike than attending physicians (50%).9 Our data, 30 years later, show that a similar percentage of attending physicians agreed that strikes were ethical (56%) and were sometimes necessary for social change (49%).
Other potential influences.
Other individual characteristics, such as gender,38 race/ethnicity,3 and political inclination,3 have been inconsistently associated with attitudes toward health care professionals' strikes. In a study of risk factors associated with participation in the 1986 physician strike in Ontario, Canada, strike participation did not vary by gender.3 In a study of psychiatry resident physicians' attitudes toward a 1992 threatened nursing strike in the United States, female residents were more supportive in general of health care workers striking (P = .05) but no more supportive of this particular strike.38
Personal agency is a person's belief that he or she can effect change. Agency is influenced by an individual's perceived ownership of a problem (e.g., “improving staffing ratios is my responsibility”) and his or her self-efficacy (e.g., “I can improve staffing ratios through my actions”). Verba and colleagues'40 civic volunteerism model posits that “political engagement” is a key determinant of individuals' decisions to participate in a political issue. In the health care strike context, engagement is analogous to issue ownership (e.g., “addressing this issue is my responsibility”), a potential obligation to become politically involved. However, in the context of health care strikes in which personal/clinical negative consequences may accrue through participation, engagement alone may not be enough to promote participation.
Bandura's31 work in self-efficacy suggests that engagement is mediated by the belief that an individual can make a positive difference through participation. In terms of participating in a strike, self-efficacy might involve asserting, “When I address this issue, I am confident that I can be successful or make a difference.” For an individual who feels ownership of an issue, his or her self-efficacy as a change agent might influence whether or not he or she takes action. Additionally, an individual's willingness to actively support a cause is influenced by professional socialization, particularly around perceptions of fairness or activism. Early in their medical education, medical students tend to be idealistic, with a frame of reference similar to that of the general public.41–47 A cross-sectional study comparing medical, law, and business students demonstrated that medical students are highly committed to altruistic behaviors and social change.48 Yet, as students progress through medical school, student perceptions of unfair treatment move closer to those of physicians, suggesting a strong role for professional socialization.41,49 In assuming their professional role, students may better understand the trade-offs and consequences of any change. For instance, in a resource-limited setting, if one group gets additional resources, another group loses resources. Alternatively, professional socialization may make students more interested in advocating the self-interest of their profession and themselves, particularly if this type of behavior is the norm, even at the potential expense of other groups (e.g., patients or insurers).
Contextual reasons for strikes
Whether or not someone decides to strike may vary depending on the situation. Contextual issues may include the importance of the issue to the individual, the consequences of striking, an individual's control over the health care environment, and public and peer support.
Importance of the issue to the individual.
Health care workers strike for a variety of issues. Some issues directly involve patient care (staff-to-patient ratios, safety issues, availability of vital equipment, etc.), and others involve worker recruitment and retention (working conditions, work hours, ancillary support, salary, etc.).5,50 In the United States, physician strikes have been exceedingly uncommon. Many physicians (even physician–employees) still enjoy relative autonomy and a comfortable salary. Thus, in the United States, practicing physicians still struggle with the question of “Is striking ethical?” as their first decision node. Depending on the health system, physicians and medical students may be more willing to support striking for patient care issues or working conditions than for salary issues.15,37 A survey of U.S. residents following a four-day work action found that residents were more likely to support strikes to benefit future patients rather than self-interest (salary).37 For Croatian medical students, patient care (91%) and poor working conditions (91%) were also more likely to justify a strike than professional status (81%) and salary (76%).15 In our survey, UC Davis medical students were much more likely to believe that striking was appropriate if related to patient care issues (71%) or work conditions (68%) than related to salary alone (43%) (see Table 1). These differences in willingness to strike over salary might be dependent on local compensation patterns.
In countries with centralized health care, it seems logical to think that physicians may feel they need professional unions or representative groups to represent their interests adequately. In those health systems, physicians may feel that they are not appropriately compensated for their expertise and effort. They may perceive limited ability to negotiate as an individual within the larger system. Under these circumstances, the question, “Is striking ethical?” may be superseded51 by the practical question, “Will this strike benefit me and my profession?” These practical issues of compensation and autonomy are important because they directly affect physician workplace morale and job satisfaction and, long-term, the ability to recruit, and retain, the best minds to medicine.
An individual with a dire personal or financial situation, who may be affected by the strike, may also be more willing to participate in change efforts around salary/benefits. Conversely, an individual who is likely to permanently lose employment through a job action might be less likely to participate, depending on his or her personal circumstances.
Consequences of striking.
The potential severity of the negative consequences of striking may play an important role in the decision to strike as well. For instance, if many patients were to truly suffer or if the individual striking were to lose his or her job or status, the negative consequences might well outweigh any potential benefit.
Control over the health care environment.
The milieu in which negotiations are occurring may be influenced by the attitudes and power dynamic of the employer or funder and the physician (attending, resident, or student). The physician may factor in the perceived effectiveness of nonconfrontational negotiations.30 An inflexible, powerful employer unwilling to negotiate on issues considered important by employees may be more likely to see job actions at his or her site.
Public and peer support.
Public support (social normalization) may also facilitate engagement in job actions.2 Physicians might feel pressured to support their union or peers in a striking decision. Conversely, they may feel more comfortable making an unpopular decision if supported by their peers.
Implications for Medical Education
Specific curricular changes can develop and expand an appreciation in students for patient-centered beliefs and professionalism during medical school.52,53 Curricula on health care professionals' strikes, which would encompass discussions surrounding professionalism, systems-based practice, ethics, economics, and conflict mediation, may help trainees develop an appreciation for the complexities of changing health systems.
For example, in systems-based practice curricula, experts involved in multiple aspects of health care delivery, analysis, or receipt might provide learners with a context for approaching complex systems issues. In such curricula, administrators could discuss the challenges that they face when making resource allocation decisions, or public health officials could discuss the difficulties in creating robust health care access programs. Union representatives (nursing or medical) might discuss the benefits and pitfalls of collective action in the health care setting, including autonomy, personal benefits, and patient care perceptions. Economists might discuss health care access, provision, and cost. Other experts might teach collaborative decision making during salary or resource negotiations. Ethicists might provide learners with cognitive tools to help them understand their values and their strategies to approach conflict. Patients and their advocates might provide perspectives on the impact of existing health care inequities and resource limitations on their day-to-day lives, as well as the impact of health care limitations during a strike. Once a framework has been developed, learners could work in interdisciplinary teams (e.g., medicine, nursing, business) to problem solve complex critical issues, such as utilization of resources, addressing health care inequities, and, when negotiations fail, exploring their perspectives regarding health care strikes.
We have included three sample case vignettes that can be used in interdisciplinary, small-group curricula to generate discussion about conflict resolution in health care and to help learners begin to grapple with some of the complex issues discussed in this article (see Supplemental Digital Appendix, http://links.lww.com/ACADMED/A45).
The authors would like to thank the medical students, residents, fellows, and faculty at the University of California, Davis, School of Medicine for their participation in completing the strike survey.
The University of California, Davis, institutional review board granted an IRB exemption.
The views and opinions expressed in this article are those of the authors and may not reflect those of the University of California, Davis, School of Medicine.
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