Doctors employed by the massive Los Angeles county health system have taken a dramatic - perhpas revolutionary - step that could profoundly affect the nationÂ's health care system.
As CBS News Correspondent Bill Whitaker reports for Sunday Morning, more than 800 county doctors voted to unionize, joining the Union of American Physicians and Dentists.
Dr. Janice Nelson teaches and runs the blood bank at the largest county hospital. She helped organize the union, she says, out of frustration.
"Five years ago, if somebody had, had told me I would be a union member, I probably would have questioned his or her sanity," says Nelson.
"Because we are continually asked to do more and more with less and less, so we canÂ't provide the type of patient-focused health care that we have been trained to provide," she adds.
Frustration has been building since at least 1995 when the system, which primarily serves poor and uninsured people, was so broke it nearly bankrupt the county. As part of the cure, doctors were laid off for the first time, clinics closed and patients turned away. The hospital administration didnÂ't consult doctors in that instance or about subsequent cost cuts.
"And this is why we want to stick together as a group of physicians, so that our voices be heard, because for long, theyÂ've been totally ignored and I think this was why the vote went down 2 to 1 in favor of unionization," Dr. Nelson explains. "ItÂ's because we want a better, a bigger say and a more important say in how we care for patients."
Dr. Donald Thomas, associate director of the countyÂ's Department of Health Services, which runs the six public hospitals and numerous clinics, calls the unionizers well-intentioned, but naive.
"People have a natural inclination to believe that if you donÂ't do what they ask you to do, you didnÂ't hear them, or you didnÂ't pay attention to them," says Dr. Thomas.
"They have discounted factors that arenÂ't going to change just because theyÂ've come into existence...budget, politics, dwindling resources, increasing indigent patients, you know, increasing responsibilities. And having a union come into play and say, Â'WeÂ're gonna improve health careÂ' is not going to solve those problems," Dr. Thomas adds.
Yet, the countyÂ's interns and residents - those sleep-deprived doctors still in training - unionized 25 years ago. And Dr. Jim Marrone, a third-year resident, says the union inoculates them against many of the systemÂ's ills.
"We have helped to fight against cost cutting and downsizing measures in the county public health system," says Dr. Marrone. "What we really exist for at the core of our organization is maintaining house staff rights. That includes working conditions, salaries."
They set aside half their last pay raise, $2 million a year, for patient care and new equipment.
"My exposure here to the union and to collctive bargaining has opened my eyes further to the need for doctors to collectively fight for the changes they see necessary," says Dr. Marrone.
Right now, Dr. Marrone and his new Los Angeles union-mates are a distinct minority. Only about 40,000 of the nationÂ's 600,000 practicing physicians are unionized, but the numbers are growing rapidly. ItÂ's a trend that Dr. Jerome Kassirer, editor-in-chief of the prestigious New England Journal of Medicine, finds disturbing. He says the whole idea of unions diminishes the medical profession.
"Ultimately, the problem is that it will come down to discussions about money," says Dr. Kassirer. "Unions are fundamentally valuable and useful for wages, for fringe benefits and not for anything else. They donÂ't improve the quality of products, and I canÂ't expect them to improve the quality of patient care."
The image that unions seem to conjure up in most minds is a faded one of blue-collar workers organizing against powerful corporate interests. ItÂ's hard for most people to view well-educated, well-paid, white-collar professionals as members of an exploited class.
But take the professionÂ's pulse today and youÂ'll find its condition deteriorating. At this summerÂ's convention of the American Medical Association, many doctors complained of being sick with frustration just like those in California.
These doctors werenÂ't railing against a cash-strapped urban health system, but rather the new world of what they consider to be profit-hungry HMOs. Managed care, they say, is sapping their autonomy, their prestige, as well as their income.
"In many ways, the physician has lost control of his practice because itÂ's almost as though thereÂ's an insurance representative in the examining room with us," says Dr. Randolph Smoak, president-elect of the AMA.
A recent AMA vote speaks volumes about doctorsÂ' dissatisfaction. It moved to unionize even though right now only salaried physicians, like those employed by Los Angeles County, can do so legally.
Under federal anti-trust law, the vast majority - those who are self-employed - are prohibited from bargaining collectively, and, in turn, from forming a true union. A bill now before Congress would lift that ban, and the AMA is lobbying hard for it.
Dr. Sam Fink, an internist in private practice, isnÂ't waiting for the laws to change. HeÂ's one of 7,000 members of the Los Angeles Medical Association, also is in the process of starting a union, despite the ban on collective bargaining.
"WeÂ're just besieged by insurance companies," says Dr. Fink. "WeÂ're being told which procedures a patient can have, which surgeries and which ones they canÂ't. And that is just not in the best interest of our patients. And the patients know it isnÂ't."
He says, however, that thereÂ's strength in numbers when negotiating with managed care firms: "An insurance company does not care about one practitioner. They might cae about a few thousand."
Managed care spread because medical expenses were getting out of hand. While even Dr. Fink acknowledges itÂ's been successful at holding down costs, he complains that managed careÂ's meddling has gotten out of hand.
The managed health industry counters that what truly galls doctors is that itÂ's holding down doctorsÂ' incomes as well.
"The money is an issue," Dr. Fink continues. "I think itÂ's primarily about patient care, but I donÂ't think the physicians have to be embarrassed about earning a respectable income, about being able to pay their employees."
But even if federal laws are changed, what leverage do doctorsÂ' unions have? For generations this was the labor unionsÂ' big stick: a strike, like when United Parcel Service employees stopped work two years ago.
But how can doctors on the picket line fulfill their solemn oath to put patient welfare above all else? Physicians on both sides of the debate agree the very idea of a strike is DOA.
"A no-strike situation is universal among all of us," says the AMAÂ's Dr. Smoak. "That is not something we would do, because it would harm patients, and weÂ're not going to harm patients."
Dr. Kassirer strongly agrees.
"Is it appropriate for physicians to strike? No! I think itÂ's never appropriate," he says. "If they decide up front that theyÂ're not going to do that, theyÂ've lost an enormous power."
Even without the threat of a strike, Los Angeles CountyÂ's Dr. Nelson says the prognosis for unions is good.
"The physician unionization effort is going to be spreading like wildfire," Nelson adds. "This is just once again expressing the frustrations that we doctors have with managed care."
Few doubt the system is sick. The question is: Are unions the cure?
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CBSNews.com staff CBSNews.com staff