Dr. Helfgott
Picket Lines: June 27 was marked on my calendar as the day to watch. No doubt the union organizers shrewdly selected it to be their strike day because of its proximity to July 1, an auspicious date for teaching hospitals, when rookie interns and residents anxiously assume their heightened roles of responsibility within the medical hierarchy. The operational disruption and relative inexperience of new cohorts of physicians has been termed the “July effect,” and evidence suggests that mortality rates rise among higher risk patients admitted to academic medical centers at the start of the academic year in July compared with May.1
The 3,300 nurses of the Brigham and Women’s Hospital (BWH) in Boston had voted to authorize a one-day strike to protest their treatment by the hospital leaders who, according to the chair of their bargaining unit, “disrespect and undervalue the nurses who provide the vast majority of patient care at the hospital.”2
Usually, workers strike for greater pay, but the financial gulf between the two sides was not wide at all. With an average base salary of $106,000 (excluding benefits) and an established contract that already guaranteed annual pay increases of 5% for their first 18 years of employment, the nurses’ grievances primarily focused on non-monetary issues. These included their opposition to changes in nurse staffing policies for one specific ward (the thoracic intermediate care unit), disputes over the formula used to calculate benefit time off (with a current guaranteed minimum of 33 days per year) and disagreements regarding their options for health insurance coverage.3,4
Fearing that major patient care issues would arise in a facility devoid of nurses, the hospital contracted with a staffing agency to hire 700 temporary nurses to replace the striking staff, not only on their designated strike day but for an additional four days. Administrators justified the need to lock out their own nurses, arguing that it was neither realistic nor financially feasible to expect to hire so many temporary workers for just a single day’s work.
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No doubt the hospital’s lock-out strategy served another purpose: to remind the union that once a strike began, there might not be a way of ensuring a happy and peaceful resolution. Consider the seminal labor event of the 1980s when the newly elected president, Ronald Reagan, declared the air traffic controllers strike to be illegal and proceeded to fire them when they refused to obey his order to return to work, leading to the dissolution of their union, the Professional Air Traffic Controllers Organization.5 The U.S. labor movement suffered irreparable harm and never regained the power it once held.
I had previously witnessed a hospital strike during my medical residency days in Montreal. At the time, strikes were commonplace events in Canada. This reality must have shocked some of the U.S. rheumatology fellowship program directors who were attempting to contact me via my hospital’s page operators to arrange my interview visits, only to be told that “all the doctors here are on strike.”
The dispute centered on medical teaching issues that related to residents aligned with the University of Montreal. Despite the fact that my hospital was a McGill University teaching affiliate, we were being pressured to show our solidarity with their cause, not only by joining their work stoppage, but also by organizing into a common labor union that would be affiliated with a very powerful one, the longshoremen’s union. Such an obvious match, eh? An alignment with the stevedores struck fear in the hearts of the hospital administrators, who preferred not to deal with a bunch of burly, angry muscular men picketing alongside their geeky comrades! It felt strange being forced to stay out of work for the several days it took for the two sides to settle the matter. In the end, the medical house staff chose not to unionize.
This vivid memory came to mind when, days in advance of the strike date, the BWH nurses held a massive, noisy rally outside the main entrance to the hospital. Throngs of enraged nurses shouting angry chants and waving handmade picket signs chastising the Brigham were cordoned off by a phalanx of Boston police. The din of the shouting and chanting seemed terribly out of place at a hospital where not so long ago, staff was applauded and admired by the community for saving lives and healing many of the dismembered victims of the 2014 Boston Marathon bombing. I felt a sickening chill down my spine.
Perhaps it was the intervention of several key city figures, including the mayor of Boston, Marty Walsh, a former union organizer, that led to a settlement a mere 36 hours prior to the strike start. Based on the agreement, it was hard to ascertain why the strike had been called in the first place. Nurses received a 2% pay hike for the next three years, the hospital gained labor peace for the length of the three-year contract, and all other grievances were to be handled through future discussions.
A sense of disrespect on the part of the hospital administrators … is a powerful emotion, one that can adversely influence one’s attitude toward work & one’s self-worth.
The Airing of Grievances
So what was the point of threatening to strike? Because money was not the focal issue, could it have been triggered by the nurses’ perception of a sense of disrespect on the part of the hospital administrators? This is a powerful emotion, one that can adversely influence one’s attitude toward work and one’s self-worth.
Nurses are not the only healthcare workers who are feeling aggrieved these days. Doctors are, too. Several recently enacted structural changes in our healthcare systems have heightened our sense of anxiety and frustration. Consider the headaches surrounding the adoption of non-interfacing (for the foreseeable future) electronic health record (EHR) systems, the challenges of scrolling through lengthier lists of equally ineffective, and often problematic, ICD-10 disease codes, the controversies surrounding the rollout of the Affordable Care Act and the thankless role we serve as unwitting gatekeepers for a system whose bloating costs continue to spiral out of control.
Would unionizing provide us with the necessary clout to exact some of the changes that would make our lives and those of our patients better? In 1935, the National Labor Relations Act guaranteed most private-sector workers, including those in healthcare, the right to unionize and bargain collectively. That changed in 1947 when the Taft-Hartley Act prohibited healthcare workers of nonprofit hospitals from forming unions and engaging in collective bargaining. In 1974, this specific exclusion was repealed and replaced with a specific 10-day advanced written notice requirement needed prior to any strike action.6
Yet doctors walking off the job remains a rare event in America. First, the U.S. population as a whole takes a dim view of strikes. People are not accustomed to and are generally annoyed by the inconveniences imposed by a strike action, and if one’s health were left hanging in the balance, there would be scant sympathy for and more likely a deep sense of resentment against striking physicians. Another reason that striking doctors in America is a rare occurrence is that many of us are either self-employed in private practice and, thus, not considered employees or work in teaching hospitals where we are considered supervisors. Based on some restrictive interpretations by the courts, this designation makes us ineligible to bargain collectively.
Nonetheless, there have been sporadic strikes. One review identified 13 walkouts in North America over the past 50 years: six occurred in Canada under a single-payer system, four involved U.S. medical house staff objecting to work conditions, primarily in public hospitals, and two were protests against soaring malpractice premiums.6 According to the authors, only three of these strikes could be judged as having achieved favorable results for the strikers. Not an impressive record.
Our thoughtful clinical judgment that has evolved through years of training carries little weight with insurers.
Just as the BWH nurses strike was not focused on money, our grievances have less to do with money and more to do with our perceived sense of disrespect. Of course, we would all love a hefty pay raise, but the reality is that our major grievances reflect our disaffection with the clout of some of the more powerful interests in the $3 trillion healthcare industry. Some of our greatest headaches, heartaches and misery can be traced to the often heavy-handed rules and policies imposed on us by these players. For example, one of the most unpleasant tasks physicians face nearly every hour of every day is the vexatious prior authorization (PA) process, an activity that masquerades as a rational review of drug therapy selection by the treating physician, but in reality reflects the battle between the titans—the health insurers and their pharmacy benefit managers on one side seeking lower costs and the drug manufacturers on the other side seeking higher prices for their products (see p. 17). Each side may have some valid reasons supporting their views: insurers are trying to rein in the rising costs of drugs, maintain insurance premiums at affordable levels and turn a profit, and drug companies need the revenue to support their research, earn a profit and satisfy their shareholders.
As physicians, we represent the patient’s needs, which are often overlooked in this process. This dilemma was recently eloquently described by a 22-year-old man with ulcerative colitis whose total colectomy may have been hastened by the sluggish and inadequate support for the use of more appropriate therapies earlier in the course of his disease that were requested by his doctor yet denied by his insurer.7 Sound familiar?
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The PA process is especially challenging for rheumatologists. Many of the diseases we manage lack randomized clinical trials that could help establish therapeutic guidelines. For many conditions, no generic medications are available. We are not like cardiologists where nearly all of their drugs, such as statins, anti-hypertensives and anti-platelet therapies, have generic options. And now we are faced with a new phenomenon, the litany of mispriced drugs—previously inexpensive products that have soared in price, thanks in part to the concept of some manufacturers buying low-volume generic drugs and driving their prices skyward.8 How about $35,000 for 120 capsules of d-penicillamine, a drug used to chelate the excess copper deposition found in patients with Wilson’s disease and formerly used to treat refractory rheumatoid arthritis?
We are left to serve as relatively powerless observers who must contend with the consequences of PA denials. Our thoughtful clinical judgment that has evolved through years of training carries little weight with insurers.
Or what about the realization that came far too late for most of us that our costly EHR systems don’t really communicate with one another and won’t for at least another five to eight years. This situation is analogous to having your smartphone being limited to making calls only to other phones on its network. Verizon could not talk with AT&T. Perhaps this strategy was a shrewd move by the predominant EHR companies that wanted hospitals and offices to avoid purchasing potentially cheaper versions from competitors that would provide a backdoor link to their more costly products. But it has made our lives more miserable as we regularly receive reams of records faxed from other systems that need to be scanned manually, page by page, and placed (or shall I say buried) somewhere in the patient’s record. Who is the winner here?
So are these grievances worthy of a work action? Sometimes I wish I had the power to fight back against these egregious policies. This is why we have RheumPAC and the ACR advocating on our behalf.
But strike? Where would that leave my patients? I have been there before, and it felt terrible being sent home from work, abandoning your patients—all to prove a point. That is vindictive behavior at its worst. There are lines that physicians should never cross, and this should be one of them.
Simon M. Helfgott, MD, is associate professor of medicine in the Division of Rheumatology, Immunology and Allergy at Harvard Medical School in Boston.
References
- Jena AB, Sun EC, Romley JA. Mortality among high risk patients with acute myocardial infarction admitted to U.S. teaching-intensive hospitals in July: A retrospective observational study. Circulation. 2013 Dec 24;128(25):2754–2763.
- McCluskey PD. Brigham nurses to vote on one day strike. Boston Globe. 2016 Jun 2. https://www.bostonglobe.com/business/2016/06/01/brigham-nurses-vote-holding-one-day-strike/bJDtsfUXAGUpQ5BlifRZUL/story.html.
- Nurses at Brigham and Women’s Hospital to hold strike authorization vote Monday, June 13. Press release. Massachusetts Nurses Association. 2016 Jun 10. http://www.massnurses.org/news-and-events/p/openItem/10038.
- McCluskey PD. Brigham, nurses lay out key sticking points in contract talks. Boston Globe. 2016 Jun 20. https://www.bostonglobe.com/business/2016/06/20/brigham-nurses-lay-out-key-sticking-points/aI0gucE3bkrEx2tkca1peM/story.html.
- McCartin JA. The strike that busted unions. The New York Times. 2011 Aug 2. http://www.nytimes.com/2011/08/03/opinion/reagan-vs-patco-the-strike-that-busted-unions.html.
- Thompson SL, Salmon JW. Physician strikes. Chest. 2014 Nov;146(5):1369–1374.
- Kling-Levin E. A medical therapy that’s no therapy at all. Boston Globe. 2016 Jul 23. https://www.bostonglobe.com/opinion/2016/07/23/medical-therapy-that-therapy-all/wttF75QVPmvEXWJknhW6MO/story.html.
- Pollack A, Tavernise S. Valeant’s drug price strategy enriches it, but infuriates patients and lawmakers. The New York Times. 2015 Oct 4. http://www.nytimes.com/2015/10/05/business/valeants-drug-price-strategy-enriches-it-but-infuriates-patients-and-lawmakers.html?_r=0.
