December 2018, Volume XXXII, No 9


Regaining the voice of our profession

A clinic’s journey to unionize

nion organizing was not at the forefront of our thoughts when we were having workplace difficulties with management. Like most professionals, we tried to address issues of concern with management—issues such as patient visit time and productivity. These weren’t necessarily new issues—our previous CEO of many years had brought up proposed changes to address the ever-increasing drive to increase productivity.

But our new CEO of one year’s duration began to push through changes with little to no input from providers. These changes not only affected patient care (shorter visits, increased numbers of visits, less time for charting/documentation, phone calls, prescription refills, etc.) but also changes to our workday that directly impacted provider work hours, access to insurance coverage, and wages and benefits.

We tried to address these issues at provider/management meetings, only to have changes implemented despite overwhelming objection. It was extremely stressful. The level of disregard and disrespect is something that caught many of us off guard. We belong to highly respected professions of medicine and nursing, recognized as such in public opinion polls, including one cited recently in Forbes (see How could we be treated this way?

The stress was so high that two of our seven medical providers left due to health concerns. Another left because he was losing family insurance coverage due to forced redefinition of work hours, despite not working any fewer hours. Management was enforcing changes, including a new employee handbook that included significant changes that had never been discussed with medical staff. These changes not only affected the provider-patient interaction, but also our livelihoods.

As health professionals, we tried to respectfully communicate with management, to no avail. In fact, these efforts to communicate were quickly labeled as insubordination. Management’s version of retribution quickly followed, resulting in suspensions, censure with verbal and written warnings. A climate of fear and intimidation prevailed without any avenue of recourse. We were “at will” employees and could be fired at any time without cause.

"Efforts to communicate were quickly labeled as insubordination."

Anonymous phone call

It was then that an anonymous phone call was made to a union organizer.

Could unionizing reopen channels of respectful communication? What would unionizing look like in our health care setting? Nationwide, many physicians are no longer practice owners (see Despite a strong regional union presence, we were unaware of any other unionized medical doctors in our area.

Some of our colleagues questioned whether professionals have the right to unionize. Yes, employed physicians do have this right (see Table 1). For example, physicians and other health professionals across the U.S. are represented by the Union of American Physicians and Dentists. In fact, many educated professions have successful unions: pharmacists, teachers, nurses, professors, and airline pilots.

The next few months remained challenging. The union organizer informed us that for a realistic chance at success we would need to get 40–50 percent of employees to sign a card expressing interest in unionizing (the card campaign).

Fear among us

Employees were initially scared to talk, scared to express interest. It wasn’t long before management found out that an organizing effort was underway. Meetings were imbued with tension and insecurity because we did not yet understand our rights and protections under the law. Despite this uncertainty, many staff spoke openly. The meetings proved to be amazingly informative and empowering. We had attendance from all employee departments. We heard stories of intimidation and bullying. As people shared their stories, frustrations, and concerns, the inevitable outcome of shared experience occurred—we realized we weren’t alone. We started to feel the strength of unity.

Management fought back, hiring a “union buster” and deploying age-old tactics of divide and conquer,  bullying, and intimidation. Some of their tactics and behavior would later be revealed as labor law violations.

Several new providers were hired to replace those who had left. These new providers joined the organization eager to perform and unaware of the ongoing struggles. While fresh perspectives have the potential to offer new vision and creative solutions, without historical context those perspectives may not recognize serious structural or organizational problems.

Other factors can contribute to physician reluctance to advocate for healthy work environments. Health professional ethics demand that we put the patients’ needs before our own. For those who work for small nonprofit organizations that exist on narrow financial margins and provide health care services where needed most, guilt is a powerful force that can “shame” physicians and other health professionals into silence about unsustainable work practices.

The union vote date was set: June 28, 2013.

The vote

Our clinic included a wide variety of job classifications, including social workers, laboratory technicians, physician assistants, dentists, and others. It was determined by consensus of management, local United Steelworkers (USW) representatives, and a National Labor Relations Board (NLRB) representative that employees would be categorized into five separate bargaining units: medical professionals, medical support staff, dental professionals, dental support staff, and non-licensed social workers. Each separate unit had its own opportunity to unionize. We continued to encourage our coworkers to vote for protection from “at will” employment status, for due process, and for a voice in the workplace. The day of the vote was tense—the outcome was uncertain.

The vote was held under strict guidelines with designated election observers from both management and staff. A federal mediator was present during the vote count. The medical professionals and medical support staff had voted in favor of unionizing. The dental and social worker groups voted against unionizing.


Efforts to communicate were quickly labeled as insubordination.

The challenges and the charges

It took another four months before we started negotiating our first union contract in October 2013. It would be another two and a half years before the professional unit would finally have a signed contract. Even though we had negotiated our own individual employee contracts in the past, negotiations for our professional unit were something for which we, as providers, were not prepared. Thankfully we had the strength and knowledge of the USW representatives and attorneys to guide us in what was to be the monumental task of achieving a first union contract. Negotiations were difficult from the first session. Not only was it difficult to sit across the table from management during negotiations, but they continued to harass employees during the work day.

Employees were reprimanded and suspended under false pretense. It was at this point that some union members took the emotionally difficult step to file charges of unfair labor practices (ULP) with the NLRB.

Following an NLRB investigation, the clinic management, including the medical director, were found guilty of 42 NLRB ULPs. (To view these, visit and search for Case Numbers 18-CA-123942, 18-CA-126399, 18-CA-129828, and 18-CA-133033). The clinic was forced to pay restitution to one of the providers and remove all reprimands and suspensions from the records of the aggrieved. Management backed off after that, but they continued intractable negotiations. After several sessions, a federal mediator had to be called in to help us move forward with negotiations.

Hard bargaining

Negotiations focused on two distinct areas: economic and non-economic bargaining. Despite most employees’ initial focus on the economic aspect, we soon learned that it is the non-economic language portion of the contract that has the most significant impact on the everyday working conditions. As medical professionals, salary was not at the top of our list of concerns. Matters affecting our workday and hours, especially policies that we felt adversely affected patient care, largely fell under the category of non-economic bargaining. Some of the most complicated issues were productivity and just cause for discipline.

Given our small USW unit size, as well as the diversity of health care professionals within it, it was challenging to ensure that the negotiated contract served the various members’ needs. We recognized that a unionized group in a larger health care organization would have advantages at the bargaining table.

After 42 bargaining sessions, we finally had a contract that we could bring to our professional unit for a vote. As a first contract, we knew that this contract was a start. We had attained our goal of no longer being at-will employees; our contract offered a strong disciplinary article that included due process. We had attained our goal of having a voice at the table.

Going forward, if management tried to change or add any policies that would affect our work conditions, wages, benefits, or work rules, they would have to negotiate it at the bargaining table. We also established a labor management committee within the contract. This committee provided an opportunity for labor and management to meet on equal footing to discuss current and foreseeable issues in order to create solutions and prevent problems.

Summing up

Establishing a union at our workplace was a difficult endeavor, more difficult than we had imagined, but it was a worthwhile journey. Not only did it provide us safeguards at our workplace, but it provided us perspective as well. Earning workers’ rights is a challenge and, for some industries, it has been a deadly challenge.

As medical professionals, we generally have the “comfort” of good wages and benefits. Ours is the challenge of regaining the voice of our professions, the challenge of regaining what it means to be a medical professional, of regaining the art of medicine, regaining the human side of medicine. Medicine, at its best, is a collaboration of many. If we are to take back our professions, then that too will have to be a collaboration, a union, of many.

Emily Onello, MD, is board-certified in family medicine. She received her medical degree in 1995.

Louise Curnow, PA-C, completed physician assistant training in 1992 and practices primary care. 

Your rights as an employed physician under the National Labor Relations Act

To form, join, or assist a union.

To choose representatives to bargain on your behalf.

To act together with other employees for your benefit and protection.

To choose not to engage in any of these protected activities.

To know that health care professionals represented by a labor organization may engage in picketing, a concerted refusal to work, or a strike, but you must comply with requirements and timelines outlined in the National Labor Relations Act.

Table 1. Source: National Labor Relations Board webpage at (accessed Oct. 5, 2018).


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Louise Curnow, PA-C, completed physician assistant training in 1992 and practices primary care.