When Sean P. Codier, DO, became a leader in the effort to unionize physicians at Salem Hospital in Salem, Massachusetts, he said he knew it was likely a “career-ender.” That is because decisions to unionize have been known to create adversarial relationships between organized physicians and their employers.¹

“We tried a variety of things before unionizing,” said Dr. Codier, an emergency physician at Salem Hospital, which is part of the Mass General Brigham hospital system. Dr. Codier and colleagues wanted to address some of the systemic issues related to the increasing corporatization of the health care industry. Many of these issues started prior to the COVID-19 pandemic but only got worse during and after the pandemic. “Unionization was a last-ditch effort,” he said.

Through his and others’ efforts, the Salem Physicians Union was formed in March 2024 to ensure that “members have a unified and impactful role in the decisions that affect the safety and quality of care of our patients.”²

Although the number of physicians who are union members is still relatively small, there is growing interest. Data from the National Labor Relations Board showed that 44 union petitions were filed with physician members between 2000 and 2022; however, there were 33 petitions filed in 2023-2024, increasing the annual rate more than tenfold from 2.1 per year to 23.3 per year.³

As interest in unionization grows among physicians, it is important to be well-informed about unions and the viability of physician unionization in emergency medicine.

What are Unions?

“In the United States, a union is a group of employees who work for a particular employer who use their collective strength to try to advance their own interests and stop the employer from doing things the union members don’t want them to do,” explained John August, director of healthcare and partner programs at the Scheinman Institute on Conflict Resolution at Cornell University. Members often pay dues to support the union.

The history of unions in the U.S. dates back more than 150 years to the formation of the National Labor Union in August 1866, which called on Congress to mandate an eight-hour workday.⁴ Today, millions of Americans are union members. Gallup polling from August 2024 estimated that seven in 10 Americans (70 percent) currently approve of labor unions, up from a historic low of 48 percent in August 2009.⁵

The right to seek better working conditions and designate representation without fear of retaliation is enshrined in the National Labor Relations Act (NLRA), passed in 1935.⁶ The NLRA applies to most private sector employers, including manufacturers, retail workers, private universities, and health care facilities. It does not apply to government workers or independent contractors, and it does not apply to physician supervisors — although the definition of a supervisor has been subject to legal scrutiny.⁷

“Health care workers originally were left out of the NLRA,” explained Alex Shulman, chief of staff for Service Employees International Union (SEIU), a union of about two million members in health care, the public sector, and property services. “Historically, physicians were working in practices with an ownership stake or were not direct employees of hospitals. There are lots of reasons why that has changed, but those changes to employment structure have created a lot more interest in unionization among physicians.”

For example, according to the American Medical Association, more than half of emergency physicians were employees as of 2020, increasing the number that qualify for union membership.⁸ The report indicated at that time that less than 30 percent of emergency physicians held an ownership stake in their practice, and more than 20 percent were considered independent contractors.

Although the NLRA excludes independent contractors from unionization, whether that exclusion applies to an emergency physician who is a contractor may depend on details of the contract.

The Fair Labor Standards Act (FLSA) did not originally outline how to determine whether someone was an employee or an independent contractor. As a result, courts defined a “common law agency test,” which gave employers the right to tell an employee what to do, how, when, and where to do the job. To apply this test, one had to determine who controls two things: what must be done and how it must be done.⁹ Other aspects that could be considered were whether the employer could fire the worker, whether the employer furnished the worker with tools or equipment and a place to work, set the work hours, required the individual to work full-time, restricted the individual from working for others, and more.

In 2024, the Department of Labor published a final rule for employee or independent contractor classification under the FLSA. Under this rule, emergency physicians thought to be independent contractors may be eligible for union formation because they meet all six of the criteria for employee status effective as of March 2024:¹⁰

1. Opportunity for profit or loss depending on managerial skill;
2. Investments by the worker and the potential employer;
3. Degree of permanence of the work relationship;
4. Nature and degree of control;
5. Extent to which the work performed is an integral part of the potential employer’s business; and
6. Skill and initiative.

Physicians and Unions

“Historically, the word union and physician were never in the same sentence,” August said.

However, unionization increasingly is being suggested as a solution to some of the challenges currently facing the industry, including lack of resources, ever-dwindling reimbursement, boarding issues, understaffing, and loss of physician autonomy.

“Everyone expects that people unionize over pay issues,” Dr. Codier said. “Being a lead organizer in our effort, I was surprised to see that after having 150 to 250 conversations, I still had yet to run across a single person that brought up pay as the first issue.”

Instead, 100 percent of the time, the concerns people had were related to the changing care environments and the patient care itself, he said.

Although uncommon, the history of physician unions in the U.S. dates back several decades. In 1959, a small group of doctors employed by the City of New York began efforts to organize to negotiate for a pay increase, workers’ compensation, sick leave, and other benefits. Known now as the Doctors Council, affiliated with SEIU, it represents doctors from New York, Illinois, Delaware, Minnesota, and Wisconsin.¹¹

There are many other large unions within the U.S. Dr. Codier and colleagues at Salem Hospital chose to organize with one of the largest public services employees’ union, the American Federation of State, County, and Municipal Employees (AFSCME). Other large unions include the Laborers’ International Union of North America, which represents health care workers among others; Communications Workers of America (CWA), which represents various private sector employees including health care; and more. Other large U.S. unions are more specific to certain industries such as the American Postal Workers Union or the National Education Association.

Outside of attending physicians, physicians in training have been organizing for years. SEIU is also affiliated with the Committee of Interns and Residents (CIR), which has a membership of more than 30,000 residents and fellows across specialties. A simple Google search for “residents on strike” or “resident unionization” will result in news stories detailing unionization efforts, resident strikes, or strikes called off from a variety of institutions including the University of Minnesota, University of Buffalo, Western Michigan University, Brown University’s Warren Alpert School of Medicine, the University of Colorado, George Washington University Hospital (www.acepnow.com/article/health-care-worker-unionization-uncommon-but-sometimes-necessary/), and more.

“In my experience, the doctors most interested in change are the younger to middle-aged doctors,” August said. “Older doctors seem to be supportive of efforts because they are worried about burnout and that doctors are leaving the profession.”

It isn’t a stretch to think that doctors who were part of a union as a resident or fellow may be more interested in forming a union later in their careers, Shulman said. “As more people graduate out of those programs and into attending jobs, I think we will slowly see more interest among attendings.”

What Can Be Bargained For?

Unions can use collective bargaining (see sidebar) to negotiate contracts that include terms of employment such as pay, benefits, hours, leave, job safety, and more.

The Salem Physicians Union crosses specialties — emergency medicine, critical care, hospital medicine, psychiatry, pain medicine, pediatric emergency medicine, infectious disease, and palliative medicine — and plans to negotiate for things specific to certain specialties. A common complaint across all specialties is understaffing. At one point, Dr. Codier said the emergency department (ED) had five open spots on its roster, leaving a lot of open shifts. The requirement to maintain staff levels could be included in collective bargaining. Salem Physicians Union is currently in the middle of negotiations related to a new observation unit in the ED; they are in discussions around the type of patients that would be placed in the unit and the qualification criteria for exclusion or inclusion.

“That is the beautiful thing about being in a union … you can negotiate the things that affect your workplace environment,” Dr. Codier said. “We want to be back in on the decision-making process for how care is provided in our community.”

Although pay may not have been the first item, Dr. Codier’s colleagues mentioned in discussions, it was an issue.

“Prior to my arrival it was normal for the organization to negotiate with an individual or a group regarding pay and benefits,’” Dr. Codier said, but this changed with time. Eventually physicians were being told what they would be paid, how much time off they would have, and how many hours they would work, with little or no input at all, he said.

Published data has shown that unionized health care workers earned better pay and received better non-cash benefits compared with non-unionized workers.¹²

Has collective bargaining worked? Dr. Codier said that he and his colleagues started to see changes even before the vote to unionize.

“As soon as it became public that we were doing this, we started to see changes,” he said. “Right away they hired five new doctors, they increased our pay.”

The horse was out of the barn though. He is quick to add that the process of unionization is not without struggles. The partnership with AFSCME provided Dr. Codier and other union leadership with protection and an advocate for their legal rights, both of which were a vital part of the process, he said.

Where are EM Docs Unionizing?

Salem Physicians Union was not the first in this wave to unionize, and likely will not be the last.

A group of physicians, advanced practice nurses, and physician assistants in the ED at Providence Medford in Medford, Oregon, unionized in 2023,¹³ and were recently able to negotiate a 20.7 percent hourly wage increase in their contract with Pacific Northwest Hospital Medicine Association.

A group of contract emergency physicians, physician assistants, nurse practitioners and lead advanced practice clinicians — contracted through TeamHealth — unionized in 2023 and spent months negotiating with Ascension St. John Emergency Department in Detroit, Michigan, before going on a 24-hour strike in August 2024. The Greater Detroit Association of Emergency Physicians saw some changes because of the strike, but it appears as if Ascension St. John did not renew its contract with TeamHealth.¹⁴ Doctors there were forced to reapply for their own jobs when a new contract management group was hired.¹⁵

More than 400 physicians at Delaware’s Christiana Care formed a union in 2024, joining Doctor’s Council. The group includes physicians from Christana Hospital, Wilmington Hospital, and Middletown Freestanding Emergency Department. They formed the union to address many of the needs outlined by Dr. Codier: patient safety, professional autonomy, and corporate influence on decision-making, among other things.¹⁶

August said he believes the formation of physicians’ unions is somewhat inevitable, and that a union at one of the nation’s leading medical institutions would create an explosion of unionization.

The NLRA mandates union membership if a workplace is unionized. Physicians considering joining a workplace where a union already exists should be fully informed about the local union.

“You have to be in the union if your group of physicians is already unionized,” Dr. Codier said of the Salem Physicians Union. “If someone had a strong moral stance against unions, they would still get all the benefits of being represented by the union but would have to pay the equivalent in union dues to a charity of some kind.” He also pointed out that, generally speaking,  most unions, including AFSCME, do not charge dues until the first contract is ratified.

Unions are not without critics or potential disadvantages. Physicians considering joining a union should be sure that the union’s positions or mission align with their own. Unions that include physicians from multiple specialties may have a range of goals that are not always aligned.

Members of a union may be called on to strike, which may be a moral concern for physicians, and is something to consider. However, striking within health care follows specific rules as stipulated by the acute care update to NLRA, which states that health care units must provide 10 days’ notice in writing to an employer of the intent to strike.¹⁷ There is also fear, founded or not, that membership in a union, or leading an effort to form a union, could influence career prospects.

“This will likely be a career-ender for me,” Dr. Codier said. “This was my last effort to improve our practice and out of that, my determination was to make sure that anybody who needs help unionizing gets that help.”

Ms. Lawrence is a freelance health writer and editor based in Delaware.

References

1. Hendrix JM, Burgart AM, Baker EB, et al. Physician Unionization: Opportunities and Challenges for Anesthesiologists in the United States. Anesth Analg. 2023;139(2):432–438.
2. Salem Physicians Union. Mission. https://salemphysiciansunion.org/mission. Accessed March 24, 2025.
3. Rooke-Ley H, Richman B, Bowling DS, et al. Unionization Efforts by Physicians Between 2000 and 2024. JAMA. 2025;333(4):347-348.
4. Terrel E. Founding of the National Labor Union and the 1st National Call for a 8-Hour Work Day. Business Librarian, Science & Business Reading Room. https://guides.loc.gov/this-month-in-business-history/august/national-labor-union-8-hour-work-day. Accessed March 24, 2025.
5. Gallup. Labor Unions. https://news.gallup.com/poll/12751/labor-unions.aspx. Accessed March 24, 2025.
6. National Labor Relations Board. National Labor Relations Act. https://www.nlrb.gov/guidance/key-reference-materials/national-labor-relations-act. March 25, 2025.
7. ACEP. Unionization. An Information Paper. https://www.acep.org/siteassets/new-pdfs/information-and-resource-papers/unionization.pdf. Accessed March 25, 2025.
8. Kane CK. Recent Changes in Physician Practice Arrangements: Private Practice Dropped to Less Than 50 Percent of Physicians in 2020. AMA Economic and Health Policy Research. May 2021. https://www.ama-assn.org/system/files/2021-05/2020-prp-physician-practice-arrangements.pdf. Accessed March 25, 2025.
9. Quarles. DOL Publishes New Rule for Determining Whether Individuals are Independent Contractors under the Fair Labor Standard Act. https://www.quarles.com/newsroom/publications/dol-publishes-new-rule-for-determining-whether-individuals-are-independent-contractors-under-the-fair-labor-standard-act. Published on January 17, 2024. Accessed March 26, 2025.
10. U.S. Department of Labor. Wage and Hour Division. Frequently Asked Questions – Final Rule: Employee or Independent Contractor Classification Under the FLSA. Accessed March 25, 2025.
11. American Medical Association. Advocacy Resource Center. ARC Issue brief: Collective bargaining for physicians and physicians-in-training. https://www.ama-assn.org/system/files/advocacy-issue-brief-physician-unions.pdf. Accessed March 26, 2025.
12. Ahmed AM, Kadakia K, Ahmed A, et al. Trends in Labor Unionization Among US Health Care Workers, 2009-2021. JAMA. 2022;328(24):2404-2411.
13. Del Savio A. Doctors at Providence Medford ratify first contract. https://nwlaborpress.org/2025/02/doctors-at-providence-medford-ratify-first-contract/. Published February 19, 2025. Accessed March 25, 2025.
14. Beresford L. The ER Docs Strike Back. ACEP Now. https://www.acepnow.com/article/the-er-docs-strike-back/. Published August 28, 2024. Accessed March 26, 2025.
15. Wells K. Detroit ER docs must re-apply for their own jobs after controversial staffing company fired. Michigan Public. https://www.michiganpublic.org/health/2024-06-19/detroit-er-docs-must-re-apply-for-their-own-jobs-after-controversial-staffing-company-fired. Published June 19, 2024. Accessed March 26, 2025.
16. Edelman H. Physicians file to unionize to address understaffing, corporatization at ChristianaCare. Delaware News Journal. https://www.delawareonline.com/story/news/health/2024/05/20/christianacare-physicians-first-in-state-to-file-to-form-union/73719214007/. Published May 20, 2024. Accessed March 26, 2025.
17. National Labor Relations Board. The Right to Strike. https://www.nlrb.gov/strikes. Accessed March 27, 2025.