It'sbeing called the blue collaring of the white coats.
In small but growing numbers, particularly in Florida and California, doctors are becoming dues-paying union members.
The AFL-CIO now represents 33 percent of the doctors in Brevard County, in central Florida, through the Federation of Physicians and Dentists Organization. The federation's membership in Florida is 2,500 - and rising.
The move by physicians, long considered wealthy entrepreneurs and members of the conservative elite, into the union hall is indicative of the profound and rapid changes under way in the nation's health-care system.
With the spread of cost-conscious managed-care companies, many doctors find themselves increasingly treated as contract labor, with less control over how much they earn, who they treat, and what tests they can order.
"Doctors must organize in an effort to regain control of their practices," says Jack Seddon, executive director of the Federation of Physicians and Dentists (FPDO) in Florida. "Managed care organizations are saying there are too many doctors. They want one doctor for 1,400 patients. Now we have one doctor for 450 patients, but managed care executives say that number is too high.
To gain leverage in such debates, doctors are paying $503 a year in annual dues to join the FPDO. The federation is working to organize surgeons in Manatee County, Fla., and doctors at Jackson Memorial Hospital in Miami. Elsewhere, the FPDO represents doctors at Cook County General Hospital in Chicago, and physicians in San Antonio, Texas, New Haven, Conn., Tucson, Ariz., and Washington, D.C.
But this is not a natural alliance. Historically, doctors have prided themselves on their independence.
"Organizing doctors is not the easiest task because physicians in general are independent entrepreneurs," says Mr. Seddon. But that status is changing. "During the past 20 years, there has been a methodical transition of the delivery of health care where the doctor was the advocate of the patient," he says. "Now the practice of medicine has been put into the hands of administrators who have no background in medicine."
And there's another obstacle to doctors joining unions: the Sherman Anti-Trust law makes it illegal for doctors to collude on price setting for their services. Physician union organizers and an increasing number of medical societies are lobbying state legislators to recognize that many doctors who work for managed care organizations are similar to employees and should enjoy the right to union representation and collective bargaining.
"Because of the restrictions imposed by anti-trust law, we really have no negotiating power," Seddon says.
Another major issue is the growing insecurity doctors feel about their income. The American Medical Association reports that earnings by physicians fell by 5 percent in 1994, the last year figures are available.
Doctors working with health- maintenance organizations (HMOs) say they often have little control over what they make. Managed-care companies refer patients to a panel of doctors, and the companies can remove a doctor from a panel with no due process. Those doctors who are invited to join a panel are often given a contract with no room for negotiating the terms.
"Really they are not agreements, they are unilateral statements," Seddon says. "The insurer says here is a provider agreement, take it or leave it.... And by the way, we have the absolute right to terminate you with or without cause and pull patients, and you have no right of appeal."
Managed-care company executives argue that such restrictions are necessary to keep medical costs down - which is an objective being demanded by the public, politicians, and its shareholders.
Arthur Hall, a physician with a thriving practice in Brevard County considers unionization essential to the future of medicine, primarily because he sees some unfair play in the business dealings between doctors and insurers.
"Airline pilots and pharmacists have found themselves challenged by the power of large corporations and have had to unionize to fight it," Dr. Hall says. "In 1947, the McCarren Ferguson Act exempted insurance companies from scrutiny. That had two effects. First of all it meant they could set prices and collude under the approval of state governments. This in effect allowed them to set up monopolies. If I set prices with my peers, the state would imprison me for violation of the Sherman Anti-Trust Act. We want to level the playing field."
Hall insists that the only place to work against the insurance lobby is through labor law. He says that a strong union would be able to lobby for changes in the present labor law and allow doctors to redress grievances with HMOs.
Hall says that eventually doctors will win recognition as employees because so many are in effect working for HMOs and preferred provider organizations (PPO). By one estimate, half of the US population is now enrolled with a managed health care company.
Alongside unions, Hall would like to see further development of independent practitioners associations (IPAs) but acknowledges that it is very difficult for doctors to start such entities because they lack clout with insurers. The goal of both unions and IPAs, says Hall, is to ensure a basic level of professionalism. He is supporting an effort to raise capital to start an IPA in the Brevard County area.
Some doctors have suggested going on strike. Indeed, in April, about 200 doctors at Howard University Hospital in Washington, D.C., staged a three-hour sit-in and threatened to strike. But Hall says such tactics tend to hurt patients more than insurers or health-care firms.
"What is happening now is that the doctor-patient relationship is being destroyed," he says. "The ironic thing is that much of American business is going toward outsourcing and contracting; the medical profession is going toward treating doctors as workers. It is a very regressive approach and is not effective. Patients cannot establish long-term relationships with their doctors."
Medical societies are taking a cautious approach to unions. A number of doctors are active in both the FPDO in Florida and the Brevard Medical Society, says Dixie Sansom, executive director of the society.
"Doctors are frustrated with regulations," she says. "In some cases when a group of doctors go to a corporation to talk about a contract they are threatened with anti-trust. Unions have been more aggressive in marketing than organized medcine has been."