Editor’s Note: This is an update to a previous version of this article which appeared online before print.

On April 18th, 2024, the emergency physicians, physician assistants, and nurse practitioners at Ascension St. John in Detroit, Mich., went on strike for 24 hours against what they say are unfair labor practices that put patients at risk.

The emergency department (ED) remained fully staffed during the strike so patient care was not interrupted; however, the union, the Greater Detroit Association of Physicians, says understaffing and poor working conditions have created an unsafe staffing situation in the ED, which has led to excessively long wait times for patients in need of care.

One way such grievances and unresolved complaints can be reconciled is through a physician union. And there are a growing number of conditions in the emergency medicine landscape that need to be addressed.

“It is sad that it has come to this. This vote to strike shouldn’t be necessary,” Michelle Wiener, MD, an Ascension St. John emergency physician, told MedPage Today.

Emergency physicians have the lowest rate of practice ownership among specialties, per the American Medical Association 2020 Physician Practice Benchmark Survey. Only 27.9 percent of emergency physicians reported having an ownership stake in their clinical practice.

For nearly three-fourths of U.S. emergency physicians who are non-practice owners, working conditions are determined through negotiations between employees and employers.

The Medscape Physician Burnout and Depression Report 2024 showed that emergency physicians have had the highest burnout rates in the House of Medicine for two consecutive years. Emergency medicine’s burnout rate was 63 percent, 10 percent higher than any other specialty. Emergency medicine has not historically been the most burned-out specialty, however. In 2018, emergency medicine had a burnout rate of 45 percent, ranking sixth among specialties.

Falling wages are fanning the flames of burnout. According to the 2024 Medical Group Management Association (MGMA) Provider Compensation and Production Report, emergency physicians’ compensation decreased by 20 percent over the past five years when adjusted for inflation, the largest drop of any specialty. Anecdotally, emergency medicine has also seen decreasing rates of group-level financial transparency and decreases in the value of benefits over the past decade.

Meanwhile, hospitals are increasingly relying upon EDs to provide more of their inpatient medical and psychiatric care, thereby limiting the resources available for emergency clinicians to care for incoming patients. “Boarding times had been stuck at around 120 minutes from 2013 to 2019. The pandemic saw the time interval increase. In the year 2021, the ED boarding time was 167 minutes, and in 2022 it soared to the 190-minute mark,” reported James Augustine, MD, FACEP, in a previous article in ACEP Now. “The average ED boarding time of 190 minutes accounted for about 47 percent of the time the admitted patient spent in the ED.”

For these reasons and more, many employed emergency physicians are looking for ways to improve their working conditions.

The option of converting from an employed group model to a physician-owned practice may seem tempting; however, hospital CEOs, rather than practicing emergency physicians, determine most emergency medicine group contracts. Practice ownership may not be an option for employed emergency physicians in most EDs in the United States.

The current negotiating power dynamic favors employers and hospitals over employed physicians, which is reflected in the working conditions of employed emergency physicians.

William Ury and Roger Fisher popularized the importance of understanding negotiators’ best alternatives to a negotiated agreement (BATNA) in their 1981 bestselling book, Getting to Yes: Negotiating Agreement Without Giving In. They wrote, “If you have not thought carefully about what you will do if you fail to reach an agreement, you are negotiating with your eyes closed.”

The BATNA for an individual emergency physician negotiating with an employer over working conditions or compensation would likely be finding a new job, often a destabilizing life event. But for many employers, losing a single physician is only a minor hiccup. Large emergency medicine employers have well-funded recruiting apparatuses ready to replace a departing physician.

Other elements of negotiating power also benefit large employers and health systems over individual emergency physician employees. For example, employers tend to have access to salary benchmarking data through organizations such as the MGMA, on which they can base compensation negotiations. Individual physicians usually can only rely on a limited amount of anecdotal comparator salary information or perhaps ACEP Now’s annual salary survey.

Some emergency physicians have started exploring the option of unionizing to gain power in contract negotiations with their employers and hospitals.

“Decisions were being made by administration that affected us and our patients without seeking input from the people with the best understanding of the situation, the emergency physicians,” said Bryce Pulliam, MD, a founding member of the Southern Oregon Providers Association union. “When we tried to reach out and share our views and concerns, our efforts were met with silence. We saw a union as a means to guarantee that we have a seat at the table to advocate not only for ourselves but, more importantly, for our patients.”

Collective bargaining is not new to health care. In October 2023, more than 75,000 unionized health care workers participated in what has been reported as the largest medical sector strike in U.S. history. Shortly afterward, a four-year contract was ratified that included wage increases and addressed staffing and training concerns.

About a fifth of U.S. interns and resident physicians are union members. The Committee of Interns and Residents (CIR), part of the Service Employees International Union (SEIU), has a membership of over 30,000 residents and fellows across 56 residencies. CIR has notched a number of negotiating victories.

Attending physicians, however, have historically been reticent about of unionization for a variety of reasons, including ineligibility (practice ownership), public perception, practice autonomy, and moral or ethical concerns. As the predominant practice model shifts to employed and the face of the health care system continues to change, many physicians are re-evaluating the advantages that collective bargaining may be able to provide.

Collective bargaining broadens clinicians’ comparative BATNA when negotiating with employers. If a negotiated agreement is not reached, an employer may lose access to its entire workforce indefinitely through a strike. A strike could cause major financial and reputational damage to the employer, disrupt essential services, and negatively impact goodwill. Additional legal protections, including prohibitions against retaliatory termination, provided by the National Labor Relations Act (NLRA) also strengthen negotiation leverage in collective bargaining.

Unions have the scale and structures to obtain and leverage information needed for successful negotiations. Unions may have the staff and resources to obtain more market-level information than individuals and can ask for a significant amount of information from employers as part of collective bargaining.

Unions can also offer individual physicians protections from health system retribution when advocating for improved patient care through appropriate staffing. This power stems from “joint employer” rules. Per the National Federation of Independent Businesses, “If two businesses are joint employers under the NLRA, both must bargain with the union that represents the jointly employed workers, both are liable for unfair labor practices, and both are subject to union picketing during a labor dispute.”

“We can have our voice heard,” said Sean Codier, DO, an emergency physician with the Salem Physicians Union, “if we collect together and represent each other in our groups, our hospitals, and hopefully together as a larger group as unionized emergency physicians.”

A panel discussion during the 2024 ACEP Leadership and Advocacy Conference, “In Order to Form a More Perfect Union…ization?” featured several members speaking about the issue.

Panelist Bing S. Pao, MD, FACEP, noted that physician owned groups (like his employer Vituity) offer their physicians access to payment transparency, as well as other decision-making abilities within the group.

“I see unionization as one solution, but not the solution for everyone,” Dr Pao said, adding that there are global issues in emergency medicine “that we need to address holistically with a number of solutions.”

“It is yet to be determined how well (physician unions) will improve the environment,” he added.

Nancy Calaway, CAE, ACEP’s Managing Director for Content and Communications Integration, contributed to this article.

Dr. Adelman (@leonadelman) is the cofounder and chief executive officer of Ivy Clinicians (ivyclinicians.io).