A 24-hour labor strike, starting on the afternoon of April 18 and called by the union representing emergency physicians and advanced practitioners at Ascension St. John Hospital in Detroit, MI, did not resolve their concerns about working conditions, staffing levels, or patient safety. But emergency doctor Michelle Wiener, MD, president of the striking union, Greater Detroit Association of Emergency Physicians, said she quickly started to notice some changes around the hospital.

“All of a sudden, the ER is staffed (with nurses and other staff) at a higher level,” she told ACEP Now after the walkout. “They’ve hired 16 new nurses in the last month. Bulletproof glass we had requested for the ED registration area is now up.” Dr. Wiener suggested that the union’s action may yet prove to be a catalyst for change for the hospital.

More recently, Ascension notified TeamHealth that it will not be renewing their contract for ED staffing, set to expire August 31 for St. John and five other hospital sites in Detroit. TeamHealth, which is a physician staffing and contract management company owned since 2010 by the private equity firm Blackstone, has managed the emergency department at Ascension St. John Hospital since 2015, when it acquired ownership of the hospital’s ED physician group, St. John’s Emergency Services, PC.

Ascension, which did not respond to ACEP Now’s request for comment on the transition away from TeamHealth, wasn’t forthcoming to its ER staff, either, Dr. Wiener said. But the doctors have heard from Independent Emergency Physicians (IEP), a small, physician-owned medical group based in Farmington Hills, MI, that IEP will be taking over the contract with Ascension for emergency medicine staffing when the TeamHealth contract expires August 31.

It remains to be seen how this will affect the local union’s status, Dr. Wiener said. But much of IEP’s leadership trained or worked at Ascension St. John and thus is familiar with its culture. “We think it’s going to be a good thing. So far, they are communicating well. It feels like progress.”

Forming a Union 

Clinicians from St. John’s emergency department, including about 43 doctors, nurse practitioners, and physician assistants not working as supervisors or residents, nearly unanimously voted to form a union in 2023. Organizing was a challenge, Dr. Wiener said. It was hard to find an established union to take them on, so they formed their own. “We meet and vote on almost everything. There’s a lot of government paperwork and reporting required,” she said.

When negotiations for their first contract stalled, that’s when they voted to strike—an “unfair labor practice” strike giving 10-days’ notice. “The strike was called to bring attention to the issues, including emergency department wait times of up to 17 hours,” Dr. Wiener told ACEP Now. “It was successful at that, without having to harm patients.” With plenty of warning from the union, TeamHealth and the hospital implemented contingency staffing plans to keep the ED fully operational.

In a prepared statement shared with Detroit media at the time of the strike, TeamHealth asserted that the emergency department at Ascension was “fully staffed” while median wait times in the ED were going down. “We have negotiated in good faith with the union and any statement to the contrary is false.”

In a more recent statement issued in June, TeamHealth stated that it had been in discussions with Ascension St. John to continue their contract for emergency services. While TeamHealth expressed disappointment in losing the contract, its “top priorities have always centered on delivering high-quality patient care and supporting our frontline clinicians.”

Zeroing in on Private Equity

The one-day walkout in one emergency department in Detroit put a magnifying glass to issues its emergency physicians had not been able to get the hospital or TeamHealth to respond to. But it has also highlighted growing attention nationally to the impact on health care from private equity firms—which today employ clinicians at one-third of U.S. hospitals. The Federal Trade Commission, Department of Justice, and Department of Health and Human Services launched a joint inquiry in April into the increasing dominance of private equity in the U.S. health care system. 

In December U.S. Senators Chuck Grassley (R-IA) and Sheldon Whitehouse (D-RI) launched a bipartisan investigation into powerful private equity firms’ involvement in the nation’s health care. On April 3, Sen. Edward J. Markey (D-Mass.) chaired the Senate Health, Education, Labor, and Pensions (HELP) Subcommittee on Primary Health and Retirement Security’s field hearing, held in Boston and titled, “When Health Care Becomes Wealth Care: How Corporate Greed Puts Patient Care and Health Workers at Risk.”

More recently, Sen. Gary Peters (D-MI), Chair of the Senate Homeland Security Committee, is leading an investigation into whether private equity’s control over hospital emergency departments is compromising patient care and potentially putting emergency preparedness at risk. Sen. Peters, who said more than 40 emergency physicians across the country have raised substantial concerns with his staff about private equity, patient safety, and emergency department staffing, recently sent letters to Blackstone, TeamHealth and other private equity firms asking them to answer questions and to plan to attend a meeting at the Senate.

On the surface, private equity-owned firms in emergency medicine seem to be having their problems these days. One, American Physician Partners closed entirely on July 31, 2023 (see ACEP Now, Sept. 12, 2023), while Envision Healthcare filed for Chapter 11 bankruptcy in May of the same year and TeamHealth faced debt restructuring.¹

Strikes and ED Doctors 

“Nobody goes to medical school intending to learn how to go on strike,” Dr. Wiener noted. “But we needed some way to ensure that we have the resources to do our jobs.” Those include safe staffing ratios for the clinicians and for nurses and other staff, with a cap on the number of beds a single emergency physician needs to cover. “We also have no paid vacation or sick time, no maternity leave, no night shift differential, no paid time for the hour we stay for shift overlap,” she said.

“I live six miles from this hospital. My kids were born there,” Dr. Wiener said. “Most of us have worked here for 15 or 20 years. We don’t want to leave this hospital. We just want things to change, to go back to what it was like to practice emergency medicine here before TeamHealth came.”

Crisis in Emergency Medicine

Harry Severance, MD, FACEP, a workforce advocate and consultant, has written widely about the growing trend toward unionization in medicine. “Many physicians have become progressively frustrated with the critical worsening and degradation of their increasingly unsafe, overburdened and understaffed clinical workplaces and many seeing little if any interest or support from an overall health care system that they see as increasingly moving toward corporate mega-system ‘profit above all’ mentality,” he said in an email to ACEP Now.

Physicians are turning to unionization as one of the few remaining pathways they see available to them to effect change and improve patient outcomes. “Will unionization prove to be a ‘panacea’ for addressing many of the ills of the health care workplace—or something else? Only time will tell,” he says.

Nurses are often leading the drive toward unionization of health professionals, but there is huge dissatisfaction among doctors—and future doctors, Dr. Severance noted. His article in MedPage Today last year cites support for unionization from an unlikely source, a frustrated hospital administrator.²

ACEP President Aisha Terry, MD, MPH, FACEP, says the field is coming to a greater realization of the understaffing, hospital system overload, and other conditions that put emergency department patients in harm’s way while adding to the moral injury of their physicians. 

“We are proud to staff the health care safety net in this country 24 hours a day. But we’re fed up with conditions that are not amenable to fully utilize, in a quality manner, the training we have as emergency physicians.” The unionization trend speaks to growing recognition of this multi-factorial crisis, said Dr. Terry, who referred readers to ACEP’s new unionization resource page. She also acknowledged that in many settings, emergency medicine residents are out ahead on the issues. 

On the day of the strike in Detroit, the Michigan College of Emergency Physicians issued a statement saying, “MCEP stands with our emergency physician members and colleagues as they fight to ensure that emergency physicians have the necessary resources to serve their patients.”

MCEP President Michael Fill, DO, FACEP, said the problems of emergency medicine include not having enough nursing staff, leading to closed beds on the hospital floors and lack of throughput, with accompanying hospital overcrowding, boarding of hospitalized patients in the ED and extended waiting times. Add to that the crisis in mental health services, where these patients can’t be transferred quickly to another facility.

He said for doctors to organize or even strike is another tool in their toolbox. “The take-home message for doctors is to realize how much of a crisis emergency departments—and the whole U.S. health care system—are facing,” Dr. Fill said. “These physicians [in Detroit] thought their only action was to form a union and strike. That says these people were so frustrated and felt they were unable to have open, productive conversations with their employer or their hospital system.”

“We are an important part of this hospital,” Dr. Wiener said, adding that doctors are starting to fight back against the private equity business model. “The problem is a real fear that when you get rid of these bigger groups, then what? There’s a real need for advocacy, and that’s where groups like ACEP come in.”

Dr. Wiener said what she has learned from the whole unionization experience, besides a lot of labor law, “is that if physicians stand together, we have a voice that is loud enough to bring about a positive change for our patients and our colleagues.”  circle-plus

References

1. Beresford L. American Physician Partners’ closing raises questions. https://www.acepnow.com/article/american-physican-partners-closing-raises-questions/. Published September 12, 2023. Accessed August 25, 2024.
2. Severance H. A manager’s perspective on healthcare unionization. https://www.medpagetoday.com/opinion/second-opinions/104932?trw=no. Published June 11, 2023. Accessed August 25, 2024.