Radical Surgery

Health care is supposed to be a personal matter. But in an age when the health maintenance organization has taken over medical care, the relationship between patient and doctor has come under attack.

Faceless bureaucrats review the decisions of doctors, measuring them against statistical charts, gauging their cost-effectiveness and denying medical coverage for care to patients using the slightest pretense. Doctors are forced to spend less and less time with each patient as insurance companies push for faster turnarounds in an effort to boost profits. The more patients a doctor sees, the more money generated for the system -- which further enriches the insurance companies and leaves patients out in the cold.

Most physicians have bought into this new paradigm of health care -- mostly because they see themselves at the mercy of larger economic forces, beset upon and forced to sign onto whatever arrangement guarantees them at least some level of compensation. Many have sought to carve out a little portion of the pie for themselves by creating doctor-run health maintenance groups, to ensure that a least some of the cash flows into their pockets. While those organizations are run by doctors, they differ very little from the standard insurance company run in that they are designed to manage care and cost, while steering cash into physicians' pockets.

Which is where the growing movement to unionize doctors comes in.

Thousands of doctors nationally have joined labor unions seeking to alter the balance of power in the medical industry. They want a greater piece of the pie, to be sure, with higher wages and better working conditions. But they also are seeking control over the way they treat their patients and to ensure that both doctor and patient are treated humanely.

New York physician Barry Liebowitz, writing in the June 1997 on-line newsletter of the Doctors Council, which represents more than 3,000 doctors in the city's hospitals, explained the union drive this way: "[D]octors now find themselves in precarious economic and ethical situations where medical decisions are being made by corporate business policy rather than medical practice." Doctors, he says, need to organize to "be a force to be reckoned with," a "countervailing power, regaining the respect, the dignity and the power over our own profession."

Dr. Anthony Tonzola of Woodbridge, N.J., told the Neward Star-Ledger that too many decisions that affect patients are being made by HMO employees with little or no medical background. "The HMOs have taken control of patient care."

Hence his decision to join with 500 other doctors in northern and central New Jersey in joining the International Association of Machinists and Aerospace Workers. Altogether, more than 700 doctors in the state have joined unions and Tonzola told the Ledger he expects several thousand more to follow suit.

The Ledger also reports that unions in California and Florida have been working for more than a decade to "increase the leverage doctors have with managed care firms." A Florida union forced the elimination of a rule prohibiting doctors from explaining to patients all the available medical procedures, even when the procedures weren't covered by the HMO. And they have made smaller gains.

Which is one reason the American Medical Association voted last year at its annual convention to work to end federal antitrust regulations that prohibit doctors from joining unions or collectively bargaining unless they are employees.

"The AMA feels very strongly that physicians have the right to come together and collectively negotiate with the various payers and players," AMA trustee William Mahood told the Ledger. "To date the balance of power has been so lopsided that most physicians feel totally forced into signing the contracts that are handed to them and they are not able to negotiate. It's usually 'take it or leave it.'"

This unionization movement is not perfect, by any stretch of the imagination. It is driven as much by their urge to protect what has always been a very lucrative gig as it is by the desire on the part of doctors to maintain the personal nature of their relationships with their patients.

Despite this, however, the move by doctors to unionize signals that they have ceased to view themselves as self-employed independent contractors or entrepreneurs, but as employees at the mercy of their employer -- the HMOs. And this realization could lead us down the road to real reform.

The current system values profits over care. It pushes doctors into often unnecessary, but lucrative specialties rather than general practice, leading to shortages of doctors in inner-city and rural areas, driving the cost of care skyward. It has led to a hideous laundry list of offenses: so called drive-by mastectomies and one-day post-partum stays for new mothers, the denial of treatment to the terminally ill, and a host of lesser evils ranging from HMOs switching patients to generic drugs without their doctor's approval to the constant realignments that force patients to change doctors more frequently than they change their socks.

Ultimately, it will have to be patients and average citizens that take back the health care system from insurance companies. For now, however, those of us interested in repairing the broken doctor-patient relationship and the moribund health care system can only hope that the unionized doctors can be the counterweight that is currently missing.

Hank Kalet, a journalist and poet living in South Brunswick, N.J., is news editor of The Central Post and the Cranbury Press.

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