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Physician leader Janet A. Jokela discusses its article “Collective action as a path to patient-centered care.” The piece reflects on the evolution of physician unions since the 1980s, beginning with housestaff associations focused on scut work and duty hours, through the Libby Zion case that transformed resident supervision, to today’s growing movement of resident and employed physician unions across major institutions. The article explains how administrative burdens, loss of professional autonomy, and physician burnout have fueled interest in collective action not to abandon patients, but to protect their care. Key insights from ACP’s policy paper Empowering Physicians through Collective Action include the need to ensure physicians have a voice in governance, safeguard them from retaliation, and prioritize patient access to safe, affordable, high-quality care. Listeners will come away with a deeper understanding of why collective empowerment may ultimately strengthen both physician well-being and the patient-physician relationship.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Janet A. Jokela. She’s an infectious disease physician and former treasurer of the American College of Physicians. Today’s KevinMD article is “Collective action as a path to patient-centered care.” Janet, welcome back to the show.

Janet A. Jokela: Thanks so much, Kevin. I’m glad to be here.

Kevin Pho: All right. So tell us what this latest article is about.

Janet A. Jokela: Yeah, ACP came out with a new position paper earlier this year about collective action, and it just made me reflect on my experience as a resident when I was in a union at that time, and also the current landscape, like why physician unions and resident unions are popping up all over the place. So, that’s where this came from.

Kevin Pho: So I think we had talked about this before. I also trained at Boston Medical Center, and you were talking about your experience as an intern at the old Boston City Hospital. I remember when I was training there, we were one of the few places that had a resident union. So during that time, I think that collective action back in 1987 when you were an intern, that was a relatively uncommon thing, right?

Janet A. Jokela: Oh, I think so. I came from Minnesota, from Minneapolis. I matched at Boston City and there I went, landed there in the big city, if you will, and they just said, “Oh, you’re a member of the union.” I was like, “OK.” I wasn’t really sure what that meant. But at that time I was really focused on, “I need to learn everything to take the best possible care I can of my patients.” I was interested in the Red Sox; they hadn’t won a World Series yet, and I was into Fenway Park, the Red Sox, and whatnot.

Anyway, I was just trying to learn everything about what was going on, including the union. At that time, it seemed like most of the efforts of the union were things like decreasing the amount of scut work that the residents were doing. So it was things like difficult blood draws, or at that time we were accompanying patients from the emergency room to the floors as interns. It was the intern’s job to push patients through the tunnels and get them up to the floor. So my recollection is those were the kinds of things the union was focused on then.

Kevin Pho: From what you remember, how successful was the union in terms of protecting the rights of the interns and residents?

Janet A. Jokela: I think they were doing the best they could with the tools they had at the time. Were we still tasked with going to the patients who no one else could get their blood? Yes. Were the interns still pushing patients through the corridors? Well, yes. But I think there were other things that they were working on too that perhaps I wasn’t as familiar with, like whether residents are considered students or employees. And at that time the decision was made that residents are actually employees, they’re not students, so they can belong to a union. So there were some fundamental things that were going on that I just wasn’t aware of. But there were a lot of other important things, I think, that were going on behind the scenes.

Kevin Pho: Today the concept of collective action is gaining traction within the physician community. I have a lot of articles on KevinMD saying that physicians should unionize. I live just outside of Boston, so we both know the primary care physicians at Massachusetts General Hospital have unionized. So tell us now, what are some of the common issues that are fueling this new wave?

Janet A. Jokela: Right. That’s a really important question and I think it speaks to the rationale behind why physician unions are popping up. I think a lot of it gets back to the sense of burnout and moral injury, and also the fact that the landscape has changed. The majority of physicians now are employed compared to in the past. So many times these employing organizations may not be quite in alignment with an individual physician’s professional ethics and professional values, and then these things clash. I think people feel like they have nowhere to go. They’re a little bit stuck and they need some help to sort this out and to provide better care for their patients and ultimately respect the values that they were trained to have.

Kevin Pho: So traditionally there’s been a belief that physicians should not engage in work stoppages. Certainly that is a way that these collective actions can assert themselves. How is today’s discussion reframing that concern?

Janet A. Jokela: Yeah, that’s an important question. I urge everyone to take a look at the article. There are a lot of details in there and a lot of in-depth review of the literature and where we are today. And there are eight separate recommendations. So with that, there’s a lot of nuance in this and a lot of rethinking physician unions.

Absolutely. I mean, I’ve heard it, you’ve heard it, I’m sure, things like, “Unions are bad. Don’t join the union.” You don’t want to be in a position where you abandon your patients. That’s not what this article is talking about. This article is talking about a new avenue and a new approach to unions so that ultimately patient care would benefit and physicians would benefit. It’s in the goal of upholding our professional values where the union can be focused, and that’s an exciting development.

Kevin Pho: So give us a sneak peek for those who haven’t read the article. You said there are some new ideas, some new approaches. Just give us a synopsis about what some of those new ideas are.

Janet A. Jokela: So for instance, with collective action, meaning unionizing and perhaps including the full range of activities, like perhaps a work stoppage, that would be a last resort. That said, there are places that have engaged in that. But for instance, if there are some physicians who might be involved in that for a short period of time, there might be other physicians who would cover for them so that patient care would not be adversely impacted.

I think the key piece is that patient care and our patients are prioritized as the primary thing and our primary motivation and focus, which is super important. And I think that guides everything else. So any actions or negotiations or mediation would really revolve around, “Hey, this is good for patient care. This is good for retaining your physician workforce.” And that’s really important because if you don’t have physicians, patients aren’t going to get care in the big picture, in the long run. So, those are some of the things that this paper touches on.

Kevin Pho: You mentioned that today’s landscape, especially for primary care physicians, has changed where the majority of primary care physicians are now employed and sometimes, as in the Massachusetts General case, they often feel powerless. What makes this group particularly vulnerable?

Janet A. Jokela: Yeah, they’re young, they’re early in their careers, they’re just out of medical school, they’re residents, and as we all know, it is so easy for residents to be in an incredibly vulnerable position. So we don’t want residents to be in a position where they’re taken advantage of in any way, shape, or form. So even things like earning a livable wage, if you will, is really important, especially in a big, expensive city like Boston or San Francisco or wherever they might be. That’s critical.

And even having avenues for childcare, how is a busy resident supposed to navigate that if there’s no easily accessible childcare right there for the residents? I like to think of the residents as the canaries in the coal mine. They see what’s going on in the hospital and they know where the pressure points are and what the problems are. So for instance, if there’s some equipment or something else that they know patients need, they can advocate for that, and collective action is one way for them to better advocate for that, and in many ways also to help them to feel like someone’s paying attention and really listening to them.

Kevin Pho: So obviously you’ve been involved with organized medicine for a long time. Now you’re in a senior position, and I’ve talked to physicians from across the country for many years as well. But how about those physicians who may not be in our positions, and they may not be accustomed and know what’s going on. Tell us the type of questions they need to ask themselves when they’re considering whether it’s right for them to join a union or not. What kind of questions or issues should they consider?

Janet A. Jokela: Yeah, great question. An important question. One is to talk to colleagues, talk to their immediate colleagues, and get a sense from them as well. “Am I the only one feeling this way? Or are other people frustrated that the time allotted for new patients has been cut from this to that? And that’s just not enough time to take really good care of new patients.” There are those kinds of issues. I think keeping the patient experience and patient care as a central focus is critically important.

And if one’s colleagues are in agreement or getting a sense that this is just wrong, I mean, like it starts to feel like this is just morally wrong. We can’t do this, it’s just wrong. And then if it comes down to either making a career change or having to leave or quit or whatever, or come on, let’s do what we’ve been trained to do and advocate for patients. I think that can make the difference.

Kevin Pho: So I know that our nursing colleagues as a profession have been more strongly associated with unionized action historically, and the concept of unions has been relatively new within the physician profession. Is there anything that we can learn from our nursing colleagues when it comes to collective action?

Janet A. Jokela: Yeah, there’s certainly been a lot more attention paid to nurses unions and nurses strikes and things like that. Again, this paper in particular and ACP is not calling for strikes, that physicians should go out on strikes. That said, there may be avenues of collaboration with nurses and nursing unions, but I think that would probably be very dependent upon the local dynamics, on the local scenarios, and local colleagues and all of that. So there may be some things that we can learn from our nursing colleagues and there may be some things that we can do together. It’s probably very regionally dependent in terms of what those might be. But yeah, the nurses unions have been in existence for a long time.

Kevin Pho: One of the things that you touch upon in your article is the concept of retaliation. So talk more about that and what kind of things that physicians should consider if joining collective action or joining a union. Is there anything that they should be on the watch for when it comes to retaliation?

Janet A. Jokela: Oh, that’s so important. It is just really important. I’m really proud of the ACP, where they’re saying that’s one of their recommendations in this paper, that physicians essentially should not be retaliated against, period. And I think it may help people in the trenches that if they’re exploring this or considering this for themselves, if they can point to the ACP paper to whoever is in charge that, “Look, these are important considerations, as far as important criteria that we will uphold and we will honor as we go forward in this.”

And I think too, that was one reason why ACP wanted to write this paper and get this out, because we know the landscape has changed. And again, there are people, residents, and physicians joining unions in pockets around the country. It’s important for them, especially to provide some guidance and a stamp of approval, if you will, that this is important for patient care and for the survival of our profession. So that’s why it’s important. It’s not the professional guild of old where we’re just protecting physician’s interests. No, this is about protecting our professional integrity and protecting our professional ethics.

Kevin Pho: We’re talking to Janet Jokela, an infectious disease physician and former treasurer of the American College of Physicians. Today’s KevinMD article is “Collective action as a path to patient-centered care.” Janet, what do you see as the future when it comes to collective action among the physician community?

Janet A. Jokela: I think it gives us hope. I think it gives us a sense of optimism and hope that there is a path forward, that this is important. And as long as physicians remain employed, there may be discrepancies between what the employer expects and wants and between what the physicians know is important and what we’re obligated to do. So I think the collective action avenue provides an opportunity to bring these groups closer together so that we can be enabled to provide the care that we know how to do, and we know is important to do.

Kevin Pho: And finally, let’s end with some take-home messages for the KevinMD audience.

Janet A. Jokela: Sure. Thank you, Kevin. Again, the landscape has changed and a majority of physicians these days are employed, and collective action provides an avenue to help better align our professional ethics and our professional commitments with the employers, thinking about what should happen and how things should be organized, if you will, in the practice.

Kevin Pho: Janet, thank you again for sharing your perspective and insight. Thanks again for coming back on the show.

Janet A. Jokela: Thanks so much, Kevin. I’m glad to be here.