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Work stoppage or slowdown: A doctor strike
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I have been reading about the difficulty that the orthopedic surgeons in Quebec are having trying to negotiate with the government.
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They are attempting to rectify a significant salary gap under which they and other specialists earn just half to two-thirds of what Canadian specialists outside of Quebec earn. As negotiations bogged down, the Quebec government, anticipating some form of work action passed Bill 37 preventing physicians from stopping, decreasing, slowing down or change the delivery of health care. The rule would impose fines of up to $35,000 per day for associations and 4 days worth of pay for violations.
Work slowdown
In reaction, some specialists began taking preliminary moves towards a work slowdown. The two sides recently reached a truce of sorts that calls for repeal of the bill and paves the way for arbitration to help close the reimbursement gap.
These events caused me to reflect on my previous experiences with work actions by physicians. My first exposure came in my last year of medical school. The hospital where I was scheduled to begin my internship underwent a work action by their house staff, and I benefited indirectly because the action ended just before I started my internship.
The work action involved a work slowdown — not discharging patients from the hospital. The successful effort led to higher wages for the house staff and, in my, case a doubling of my expected starting pay. It meant I had a living wage for the first time in my training and education. I had not participated in organizing nor voting for that "heal in" but came just in time to benefit.
Ethical work stoppage
The next job action for me came in 1975 when a malpractice premium situation arose in California. Many physicians felt it was a "malpractice coverage crisis." All the physicians, including our leadership, wrestled with the issue of a work stoppage and how it could be done in an ethical way that did not cause patient harm. Many of us were convinced we would eventually have to close our practices permanently if we did not get some relief and reverse the escalating premium trend. In Los Angeles County we voted to close our "elective practices" (surgery and office) for a period. We decided to treat emergency and urgent conditions only. That type of action and other coordinated efforts led to limits on punitive damages. Passage by our state legislature of the Medical Injury Compensation Reform Act resulted in a relatively stable insurance situation for surgeons in California that has persisted ever since.
I am certain that at some point a new situation will evolve (e.g., Medicare reimbursement) that will spark some type of work action by enough physicians to effect change, though it is difficult to say just how or when. My limited experience has taught me that work actions never will be a pleasant and will be difficult for individual physicians to organize.
Physicians agreement
It was difficult saying "no" to patients for non-emergent care. Many physicians refused to participate in the work stoppage and expect that to occur in any similar, future actions.
In that California case the medical association in the adjacent county (less than 7 miles from my office) decided not to participate, of my several existing patients and potentially new patients went to the adjacent county physicians for care. Their only inconvenience was the additional travel time.
Disagreements between physicians and patients will arise during work stoppages and some immediate review process for disputes would have been helpful back in 1975. I remember an eye-to-eye confrontation with a neurosurgeon in our operating room that involved considerable emotion and heated words. He felt the surgery I was about to perform on a young college student did not qualify as emergent.
He blocked the entrance to the operating suite preventing the patient from being rolled into the room. The exchange changed our relationship permanently. A well-thought-through review process could reduce the likelihood of such disputes.
I remember thinking during and after that job action that events moved rapidly and communication could have been better. It is hard to imagine the next crisis that will unite physicians to take part in a collective action. Physicians now work in so many different practice and reimbursement settings — HMOs, PPOs, state- and county-run programs, government facilities, as well as industrial and medical legal practices, just to mention some.
Few orthopedic surgeons are currently in unions and well under 40% belong to general medical organizations (e.g., the American Medical Association). One reason: They are usually controlled by primary care physicians. I feel fortunate to be a member of strong and active state and national orthopedic organizations.
They will monitor and interpret upcoming problems and can mobilize surgeons. We could then network with other physician groups at the local level where issues usually get worked out. Trying to get physicians to come together for an effective "work stoppage" or "action" will never be easy.
If I ever participated again in a work stoppage or slowdown, I would want to see the several things in place in advance, most notably the following:
- a written action plan with a defined end point;
- adequate funds to execute the plan, including money for media and other public relations activities;
- certainty that a critical mass of physicians are committed and on board for the duration;
- a review panel to resolve conflicts that arise involving criteria for inclusion, patient care issues and ethical standards;
- consideration towards paying or subsidizing physicians who evaluate treat or triage patients;
- a means of communicating the status of the effort, with regular open meetings with meaningful input from involved physicians;
- (ideally) a select group of responsible consumers (patients) to help monitor, comment and oversee the action;
- medical organizations administering the action that cooperate and not duplicate costs and administrative red tape.
Let us hope we have no need for collective or individual job/work actions in the future. But it is likely we will in this evolving health care environment and with the current price controls imposed by Medicare.
Douglas W. Jackson, MD
Chief Medical Editor