Patient volume is up, staffing is down,and emergency physicians have had enough
A group of 13 emergency physicians, three ED physician assistants, and one ED nurse practitioner at Providence Medford Medical Center in Oregon unanimously voted to unionize in late April, saying that it was a last resort to make the hospital listen to their concerns about patient care.
“Our primary concerns really revolve around patient safety, and I am sure they are not unique to our hospital,” said emergency physician David Levin, DO, who is acting as the spokesperson for the Southern Oregon Provider Association. “Our patient volumes are much higher than they have ever been. Part of that, I assume, can be attributed to the loss of primary care. Patients are leaving without being seen at higher rates than in the past because we have less staff to deal with the volume of patients.
“Over the last several years, we have lost specialty services, which means we are holding people in the emergency room while trying to transport them all over the state and even out of state. We have sent people to Idaho, Nevada, Washington, and California. That's not good for the patient.”
Patients expect ordinary hospital services to be available, Dr. Levin said, adding, “They do not expect to be sent away from home for something that is not tertiary care.”
The emergency medicine group tried to make the hospital administration aware of the problem, but found responses were not forthcoming. “One of our doctors finally said, ‘We have asked for meetings, we have sent letters, we have sent emails, and nothing is happening. What are our other options? The only other way to get a voice, a meaningful voice, at the table is unionization,’” Dr. Levin said. “Once we arrived at that conclusion and did our homework about what we gain and what we lose, it was remarkably quick. We started talking about this in earnest in January,” and the April 25 vote sealed the deal.
Dr. Levin and his colleagues took on a health care giant. Providence Medford is part of a nonprofit Catholic health care system that owns 51 hospitals and 1000 clinics in Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington. An article in The New York Times described it as a “multibillion-dollar institution in the Seattle area [that] invests in hedge funds, runs a pair of venture capital funds and works with elite private equity firms like the Carlyle Group ... one of the country's largest and richest hospital chains [New York Times. Oct. 22; 2021; http://bit.ly/3o9y3KX]. It is sitting on nearly $12 billion in cash, which it invests, Wall Street-style, in a good year generating more than $1 billion in profits.” (May 25, 2020; http://bit.ly/3MBVdDM.)
The newspaper noted that nonprofit Providence obtains its funds from private donations and investments with hedge funds and its profits from treating patients. Providence also runs its own venture capital firms that invest cash in cutting-edge startups.
Techs, Not EPs, Hired
Providence Medford Medical Center has 120 beds, and it had 32,594 ED visits in 2022, with 990 of those patients admitted, spokesperson Julie Howard wrote to EMN in an email. She noted that the hospital's budget is not publicly available, but budgeted expenses for the ED increased 18 percent in the past five years. Ms. Howard said the hospital added positions to the ED in 2023, and now has 76 full-time equivalent positions, which is eight more than the highest count in the past five years.
Christopher Pizzi, the CEO for Providence's Southern Oregon service area, which includes the hospital and a number of clinics and home and community care services, continues to address staffing issues with his leadership team, she said.
“None of the increased budget has gone toward provider staffing or salary,” said Dr. Levin. The ED recently received permission to hire another doctor because other doctors have cut back on their hours, but the staff is not gaining any extra coverage hours, he wrote in an email to EMN. Any increase in FTEs in the department has been from hiring techs, he said.
Dr. Levin and his group are directly employed by the Medford hospital, which makes forming the union easier than if they were under a contract management group. Their employment, however, makes practicing medicine difficult, he said. “As the hospital had trouble recruiting and retaining specialists or even hospitals and critical care doctors, more and more of that responsibility gets shoved down to the emergency physicians,” Dr. Levin said. “We are holding patients [in the ED] in numbers we have never seen before.”
He said they have been asked to take on extra responsibilities, such as procedures in the ICU. So far, the medical director has protected them from those tasks, but only after the idea was brought up repeatedly by the administration.
Dr. Levin and his group petitioned the National Labor Relations Board for an election on an ED union by showing at least 30 percent interest in such a move. Then the union served a petition on the employer, along with a description of NLRB procedures and the rights and obligations of all parties and a statement of position.
The NLRB regional director investigated the petition and served the parties with a notice of hearing. The employer then describes issues it plans to bring up in the hearing, and then the union responds. Dr. Levin said his group was awaiting their ballots, which they were scheduled to cast in April. The NLRB is supposed to rule soon.
The Oregon Nurses Association said it would support the EPs in bargaining their first contract and assist with grievances as they do with two other groups of physicians located in the Eugene area. The issues raised are not salaries or benefits, although some salaries were cut during the pandemic, Dr. Levin said. “It's a whole group that wants to take back control of the ER,” he said. “We don't really have burnout. We have moral injury. That is caused by being prevented from doing what we think we should for our patients.”
Wendy Dean, MD, who is credited with coining the term moral injury, said its root is a transgression of deeply held moral beliefs and expectations. (EMN. 2022;44:1; https://bit.ly/3WDbtGV.) “In health care, those are the oath [and] the promises that we make to put our patients as our first priority,” she said. “What drives the transgression is something from another definition of moral injury, which is betrayal by legitimate authority in a high-stakes situation, the sense that not only am I being driven to forsake my oath, but it is by the demands of somebody who holds power over me in some way.”
Medford Medical Center's spokesperson, Ms. Howard, wrote in an email that they believe that an ongoing direct relationship with their providers is the best way to continue offering the best care for the community that relies on them. “[W]e will respect the choice that our providers [made] ... and will bargain in good faith over mandatory subjects of bargaining.”
MS. SORELLE has been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.
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