When I began my internal medicine residency in 1987 at Boston City Hospital, all new interns were enrolled in the Housestaff Association, the residents’ union. Some of my resident peers were active leaders in the union. Coming from Minneapolis and moving to Boston, I was trying to absorb all the new things (such as Fenway Park and the jinxed Red Sox, in the pre-world-champion days) and keep my head above water to do best by my patients, while also learning more about everything else, including the housestaff union.

Union activities at that time focused on minimizing the dreaded “scut work” (such as difficult blood draws) and how often interns really had to accompany patients from the emergency room to the floors (we routinely pushed them, on their gurneys). Our duty hours were usually well over eighty hours per week, and there were times we worked thirty-two hours or more straight and did it again a day or two later. Duty hours were not under discussion, and we just accepted them as “what we do” (although certainly they were not easy and many of us were quite miserable, and tired).

What has happened since then? The tragic Libby Zion case in New York City drew massive attention to resident duty hours and supervision. The Accreditation Council for Graduate Medical Education (ACGME) issued duty hour regulations for residents. The ACGME also created a confidential (and needed) ombudsperson, so any resident in any program could report a concern or complaint, anytime. Today the focus is on quality resident education, wellness, and excellent patient care, with some lingering tension between “the old days” (though not as much as before) and this new paradigm.

What has happened to physician unions? While hospitals in New York City, as well as Boston City Hospital, were some of the early adopters to embrace resident physician unions, more have popped up around the country. The recently established resident union at Harvard’s Massachusetts General Hospital in Boston was big news. Resident concerns that prompted its formation were things like low resident stipends (in the expensive city), a desire for increased support for childcare, and more equipment for patient care. Resident unions have also cropped up at the University of Pennsylvania, Stanford, and George Washington University, amongst others, all prompted by similar concerns. In addition, we now hear of employed physicians joining unions, something relatively rare until recently.

So why are we seeing this? ACP provides insights on this issue in its thoughtful and powerful policy paper published earlier this year, Empowering Physicians through Collective Action. ACP asserts that physicians today have experienced increasing administrative burdens, the erosion of the patient-physician relationship, and diminished agency, all leading to a sense of physician disempowerment and low professional fulfillment. Physicians have begun to explore collective action to “enhance their ability to deliver high-quality care to patients, regain control of their profession, and improve their well-being.”

As we all know, the longstanding position in medicine has been that physicians should never abandon their patients by participating in collective actions such as work stoppages, thereby limiting or denying care to patients. Today, a majority of physicians are now employed and many, particularly primary care physicians, report they have been rendered increasingly powerless to advocate for the requisite working conditions that would allow them to provide quality care for their patients. In other words, consideration of some type of physician collective action may be an avenue to ultimately benefit patients. Physicians are trying their best to uphold their oath, and some are feeling like their backs are up against the wall. It has been asserted by some that health care today depends upon the exploitation of physicians and their commitment to their patients.

Some key recommendations from the paper include the “primary objective of collective empowerment actions by physicians should be to ensure that patients have access to safe, affordable, high-quality care … ACP supports using collective empowerment actions to improve quality of care, health equity, the patient-physician relationship, and physician well-being.” In addition, “ACP supports research into the effects of physician collective empowerment actions on patient care and physician well-being.”

“Practicing physicians must be included in executive positions and have voting privileges on hospital and health system governing boards…”

Physicians must be protected from retaliation, and “stepwise actions should only be considered once all other negotiating tactics have been exhausted and efforts have been made by all involved parties to ensure safe patient care.”

The paper contains eight explicit recommendations and valuable background information. Please do take a look.

Physician unions have been around for decades and are continuing to evolve. We know patients come first. And today, physician collective action may provide an avenue to ensure that patients and improving patient care remain there, as number one. That, is something we can support.

Janet A. Jokela, MD, MPH, completed her term as ACP Treasurer at IM 2025. She serves as professor and senior associate dean of engagement at the Carle Illinois College of Medicine, Urbana, IL. She may be reached on BlueSky @drjanetj.bsky.social.

The American College of Physicians is the largest medical specialty organization in the United States, boasting members in over 145 countries worldwide. ACP’s membership encompasses 161,000 internal medicine physicians, related subspecialists, and medical students. Internal medicine physicians are specialists who utilize scientific knowledge and clinical expertise for diagnosing, treating, and providing compassionate care to adults, spanning from those in good health to individuals with complex illnesses. Stay connected with ACP on X @ACPIMPhysicians, Facebook, LinkedIn, and Instagram @acpimphysicians.