When Doctors Join Unions (review)

When Doctors Join Unions is a historical and sociological study of an independent California physicians’ union, the Union of American Physicians and Dentists (UAPD). The UAPD serves as a collective bargaining agent for the 40 percent of its five thousand members who are salaried physicians, mostly in state and local governments, and as an “attorney or management consultant” (p. 129), primarily on reimbursement problems, for the 60 percent who are private practitioners.

The UAPD was organized in 1972, in a period when about two dozen physicians’ unions were established throughout the United States. At its peak in 1980 it had about ten thousand members associated with affiliates in sixteen states. Currently the author knows of only two physicians’ unions, the UAPD and the Doctors’ Council, a New York City union with three thousand salaried physicians that was organized in 1959. The other unions failed because physicians viewed unions as “inconsistent with medical professionalism” and strikes as “unacceptable” (p. 17). The UAPD survived by becoming “a formal, rational organization staffed by experts who provide a range of specific services” (p. 139).

An analysis of physicians’ groups in Europe (many of which are not unions) indicates that “whether unions are militant or conciliatory depends upon the larger context of social understandings and expectations” (p. 28). In America, individualism has been the “dominant value system” (p. 31). The author believes that “medicine’s ability to assert its professionalism and to enjoy the rewards thereof has been slipping” (p. 33). Rising medical costs and the feminist and patients’ rights movements have created public criticism. In the 1970s legislation was enacted to encourage HMOs and public participation in health planning. Physicians’ emphasis on individualism waned in the 1970s due to corporate ownership of health-care facilities. The AMA, which condemned physicians’ unions in 1973, later established a Department of Negotiations to help physicians negotiate with health-care corporations. By 1992, 70 percent of AMA members derived some income from managed-care organizations.

The legal status of physicians’ unions is “unsettled” (p. 121) due to the 1947 Taft-Hartley amendments to the 1935 Wagner Act (not discussed). These permit professional employees to organize separate unions (thereby avoiding multioccupational unions) but deny supervisory and managerial employees the protection of the act (companies need not negotiate with them and can dismiss them for joining labor unions). Budrys describes the 1980 Supreme Court ruling that some salaried professionals are managers, which hinders the unionization of salaried physicians. The Wagner Act exempts most self-employed workers and all public employees, which enabled the state of California in 1981 to let the UAPD represent salaried physicians employed by public agencies.

Budrys does not reach a conclusion on whether the UAPD is a “harbinger or anomaly” (p. 138), but information not provided in the book suggests one. Union membership has declined from one-third to less than one-sixth of the labor force in the last three decades. Unions remain strong only in the public sector, where the scope of collective bargaining is restricted. Most states employ few salaried physicians, and many limit public employee unionism. The UAPD’s activities for its members in private practice are not labor union functions. The UAPD is clearly an anomaly.

This book has many weaknesses. Budrys displays limited knowledge of the labor movement, labor law, and organized medicine. She never defines labor unions and so cannot differentiate them from professional associations. Her contention that collective action by physicians was rare in the past is contradicted by histories of medical societies. The UAPD’s interesting history is scattered throughout the book and presented haphazardly (e.g., the “dentists” in the organization’s name is never explained). The author’s acceptance of Parson’s model of professions is an anomaly today.