Ethics of Physician Strikes in Health Care
Su-Ting T. Li, MD, MPH Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, California
Malathi Srinivasan, MD Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
Richard L. Kravitz, MD, MSPH Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
Michael S. Wilkes, MD, MPH, PhD Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
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Case
Anesthesiologists employed by a large regional medical center in the United States have been in contract negotiations with the hospital administration for the last 6 months. Negotiations appear to have stalled. The hospital claims the anesthesiologists’ demands for higher salary and more vacation time are unreasonable: “They just want more money.” The anesthesiologists claim they want safer working conditions: “Being on-call 24 hours at a time is unsafe. I am not as alert at 3 AM when I have been up since 5 AM the day prior.” A practice partner recalls an anesthesiology strike in Costa Rica in 2011 in which the hospital claimed the anesthesiologists wanted more money, whereas the anesthesiologists stated that they wanted better operating room ventilation and safety measures.1 He suggests that the group consider striking. The US anesthesiologists in the stalled contract negotiations consider the following questions: (1) Is it legal for physicians to strike? (2) Is it ethical for physicians to strike? (3) How should physicians ensure individual patient welfare during a strike? REPRINTS: SU-TING T. LI, MD, MPH, DEPARTMENT OF PEDIATRICS, UNIVERSITY OF CALIFORNIA DAVIS, SCHOOL MEDICINE, 2516 STOCKTON BLVD, SACRAMENTO, CA. E-MAIL: [email protected]
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(4) Have physician strikes been successful? (5) Should I, personally, go on strike? ’
Background
Physician strikes have been relatively rare in the United States. However, recent changes in the health care landscape and societal expectations may lead more physicians to consider job actions, including strikes. As the health care marketplace in the United States consolidates, more physicians are being employed by large health care organizations.2 As a result, physician autonomy has diminished, and more physicians find themselves negotiating over their conditions of work with large health systems or insurance plans. As professionals, physicians have previously enjoyed a great deal of autonomy, including self-governance of their own profession, selection of who gains entry into that profession, independent decision making, and assessment of what constitutes fair reimbursement. As employees, rather than self-employed practice owners, physicians are seeing their autonomy challenged and their salaries and benefits dictated by others. They are often expected to see more patients, and the care they provide, such as the length of visits, may be constrained by the dictates of their employer.3 As more physicians move from being self-employed, autonomous professionals to contract employees, physicians find themselves faced with the same concerns that employees have faced since the start of the industrial age: negotiation for fair wages, benefits, and safe work conditions.4 In addition, physicians have the added privilege and fiduciary responsibility of advocating for the best interest of their patients.5 For physicians, strikes create an ethical tension between a duty to provide care for current patients versus striking to advocate for better care for future patients through system improvements (improving safety, equity, quality of care, pipeline of future physicians). This ethical tension is further intensified when the public perceives the strike would result in personal gain for physicians (improved salary, better benefits, lower malpractice costs, or more vacation time) at the expense of potential harm to the patient through lack of immediate care. This paper explores the ethics of physician strikes in health care. We discuss collective bargaining laws in the United States, the ethics of physician strikes, the modern history of physician strikes, and the potential future of physician strikes. Collective Bargaining—Is it Legal for Physicians to Strike?
Strikes, or work stoppages, originated during the industrial age as more people moved from being autonomous workers to salaried www.anesthesiaclinics.com
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employees wherein their workplace, wages, working conditions, and employment were dependent on others. Groups of workers shared common concerns for welfare and well-being, which drove them toward unionization and then collective bargaining. Job actions, including strikes and work slowdowns, emerged as an approach unions used to promote negotiation with their employers when all else failed. The effectiveness of a strike was greatest when work disruption resulted in economic pain for the employer, even when the strike would temporarily adversely affect the individuals striking as well. The United Nations’ Universal Declaration of Human Rights contends that “everyone has the right to form and join trade unions for the protection of his interests”; “everyone who works has the right to just and favorable remuneration”; and “everyone has the right to freedom of peaceful assembly” and “the right to freedom of opinion and expression.”6 Some have interpreted this as physicians having the same rights as other employees—to collectively bargain and protest and a right to strike should negotiations fail.7,8 In the United States, collective bargaining by employees did not have a strong legal basis until the National Labor Relations Act (NLRA) of 1935; until then labor organizers had been potentially subject to prosecution for violating antitrust and racketeering laws. The NLRA provides the policy framework around which groups of employees may collectively negotiate with their employer. Physicians who are independent contractors or supervisors (exercise independent judgment to assign responsibilities and direct other employees at least 10% to 15% of the time)9 are not covered by the NRLA.9 Health care workers who fall under NLRA may legally unionize, engage in collective bargaining, and strike with a 10-day written advance notice.10 Dissatisfied employees have 2 major options—they may “exit” or give “voice” to their concerns.11 Physicians, in particular, may “exit” by choosing to practice elsewhere, limiting the type or number of patients they care for, leaving their profession, or not entering it in the first place.12 This “exit” may be reflected in the type of employer for whom a physician works (profit vs. nonprofit, religious vs. secular, government vs. private), the specialties that physicians choose to train in,13 the countries or regions in which they practice,12,14 the types of insurance (public or private) they choose to accept,15 how much clinical time they practice (vs. conducting research or performing administrative duties), and their chosen age of retirement.12 Alternatively, physicians may give “voice” to their concerns individually or collectively. Individually, physicians may choose to complain to elected officials, write letters to the editor, and contribute to political campaigns or action committees. If they find individual action inadequate, they may choose to collectively protest, lobby, or use their collective bargaining to negotiate. If collective bargaining is not www.anesthesiaclinics.com
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effective, they may seek mediation, binding arbitration, or as a last resort, conduct job actions such as sick-outs, slowdowns, and strikes.16
Strikes and Medical Professionalism—Is it Ethical for Physicians to Strike?
Typically, physician strikes result in the temporary cessation of usual patient care activities. For some, physician withdrawal from patient care challenges traditional ideas about medical professionalism and professional standards. The Physician Charter on Medical Professionalism, endorsed by >130 physician organizations worldwide, defines 3 guiding principles at the heart of medical professionalism: (1) primacy of patient welfare, (2) patient autonomy, and (3) social justice.5,17 The principles of patient welfare and social justice are often considered when discussing the ethics of strikes. For some physicians, patient welfare is the overriding principle making the thought of any strike unethical and indeed unthinkable.18,19 For others, this principle extends to the welfare of future patients and may pair with the principle of social justice to allow physicians to be open to the possibility of strikes depending on the circumstances and the potential for positive future change.18 Social justice is an underlying principle of the World Health Organization (WHO), which in 1948 declared health a fundamental human right.20 Since that time, the WHO has recognized that to achieve the goal of universal health coverage, several factors are needed, including a “strong, efficient, well-run health system,” “a system for financing health services,” “access to essential medicines and technologies,” and “a sufficient capacity of well-trained, motivated health workers.”21 As access to health care is expanded for a larger percent of the population there may be a tendency to centralize systems for financing health services to maximize efficiency. There will also be new guidelines and rules to govern practice, which may not be agreed to in parts of the medical community. Within the United States, there are potential conflicts between health care institutions, insurers, specialty groups, and government oversight groups. Each may argue in the public arena that their goal is to promote patient welfare, whereas others argue that the same goal is primarily self-serving and protectionist. At times, advocating for “best care” for future patients may mean compromising on “best care” for current patients. There are already precedents for this. For example, renovating old facilities or replacing outdated equipment may improve the ability to care for patients in the future, but may temporarily reduce capacity to care for patients during the renovation or delay care during the transition from old to new equipment. Transitioning to an electronic health record may lead to an increase in communication between providers, but may temporarily lead to fewer patients being seen as providers learn the new system. www.anesthesiaclinics.com
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When physician strikes are considered, the issues are often murky. Physician strikes frequently have overlapping patient welfare–centered goals (ie, patient safety, safe working conditions), social justice–centered goals (ie, access or population health), and profession-centered goals (ie, wages and benefits). Unsafe working conditions not only affect physician health and well-being, but may also affect care of both current and future patients. Working too many consecutive hours may jeopardize the safety of current patients if sleep-deprivation impairs clinical judgment.22 Increased security in hospitals would improve safety for staff and for patients. Some may argue that at some point, by neglecting to advocate for fair wages and working conditions, medicine loses the ability to attract and retain a “sufficient capacity of well-trained, motivated health workers”21 as required by the WHO to realize universal health coverage. For example, a study by the South African Medical Association estimated that government doctors in South Africa are underpaid by 50% to 75%; in turn, South Africa has a 30% medical staff shortage.23 Strike context is an important factor when health care workers consider whether or not a strike is personally ethical. Medical students, residents/fellows, and physicians are more likely to support strikes related to patient care or work conditions than strikes related to salary.18,24 A 2005 survey in a single US medical center found that medical students were more likely to support physician strikes for patient care issues (71%) and work conditions (68%) than salary (43%).18 Although the pattern was similar in faculty physicians, fewer faculty physicians supported physician strikes for any reason, with 44% supporting strikes for patient care issues, 42% for work conditions, and 20% for salary issues. As physicians balance the welfare of their present patients against that of future patients, protesting unsafe working conditions and lack of equipment, and, potentially, deterioration of respect and poor compensation driving potential future physicians into other fields, job actions may move from unthinkable to an important means to negotiate essential changes. How Should Physicians Ensure Individual Patient Welfare During a Strike?
For many physicians, the decision of whether to strike involves weighing the likelihood of a strike’s achieving its objectives against the potential harm that a strike may cause. As health care is an essential service, a traditional strike with full withdrawal of physician services could considerably harm patients. To minimize patient harm, striking physicians often exercise substantial discretion in the intensity and duration of withdrawal of patient services.25 Although some have argued that physician withdrawal of services is not unusual (eg, when www.anesthesiaclinics.com
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they go on vacation, are sick, retire, or move away),26 there is usually planned physician coverage when this occurs. This may not be available during a strike. Therefore, even ardent supporters of health care strikes argue that strikes need contingency plans to care for the sickest patients, including providing emergent/urgent surgeries and emergency care.27 Good contingency plans mitigate the impact of a strike on current patients. When outpatient physicians strike, emergency department utilization increases during the period of the strike. A 2003 work slowdown of outpatient physicians in New Jersey resulted in a 79% increase in total patient volume seen in the emergency department and a 223% increase in pediatric volume.28 An outpatient physician strike in Canada in 2002 led to a decrease in outpatient antibiotic prescribing for pediatric pneumonia but no change in incidence of radiographically diagnosed pneumonia in the emergency department during the strike, indicating that the sickest patients were still able to receive timely care.29 In some circumstances, striking may have no short-term effects on measurable mortality rates. Strikes of resident physicians-in-training often lead to no change in mortality because faculty physicians assume care.30 Studies in emergency departments during resident strikes found that both quality of care31 and efficiency30 increased during a resident strike because faculty physicians, with more experience, assumed the care of patients. A review of the impact of physician strikes between 1976 and 2003 on patient mortality found a decrease in overall mortality during the period of strikes because of a decrease in numbers of elective surgeries during the period of the strike; emergent surgeries were still performed.32 No changes in the quality of emergency care, such as appendectomy care, were noted.33 The lack of increase in mortality seen is likely due to both the length of the strikes (with potentially longer strikes leading to more negative outcomes) and the thoughtful contingency planning to care for patients with emergent and urgent conditions (which would not be seen with a complete withdrawal of services). Recent strikes with complete withdrawal of services have led to patient deaths.34 However, adverse consequences of physician strikes may be seen even with the best-laid contingency plans, particularly as the length of the strike increases. A 20-day physician strike in South Africa in 2010 was associated with fewer patients admitted to the hospital and lower overall mortality, but a higher mortality rate of the patients who were emergently admitted.35 The longer the duration of the strike, the more difficult it is for health care contingency plans to provide adequate care to the population. In a 118-day physician strike in Israel in 1983, patients, particularly those with limited access to health care choices, perceived the strike damaged their health despite the establishment of alternative care centers and availability of emergency rooms to minimize potential harm to patients during the strike.36 www.anesthesiaclinics.com
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Modern History of Physician Strikes—Have Physician Strikes Been Successful?
Withdrawal or cessation of clinical services (striking) is the most extreme form of collective action. Physician strikes over the past 20 years have varied in purpose and success (Table 1). Health care provider strikes may have a negative impact on health care providers overall, if the public does not support the rationale surrounding the strike or if patient harm results from the strike. This negative public view increases if the strike is considered primarily physician welfare–centered rather than patient welfare-centered.2,25,36 Physicians, even when employed, are usually high wage earners, relative to the average wage earner. Yet, the practice of medicine is tightly regulated. Professionals in less tightly regulated fields have the ability to increase or decrease their professional fees more easily. A strong negative reaction was seen during the Ontario, Canada strike in 1986. In this strike, physicians went on a 23-day strike to try to prevent a federal ban on “extra-billing” (charging more than the amount payable by the Ontario Health Insurance Plan for providing an insured service). The strike failed to prevent the ban from going into law, and it also alienated the public.25 Looking Toward the Future of Strikes in Health Professionals—Should I Strike?
The interplay of several factors may impact the frequency of health care strikes: increasing health care needs paired with the need to decrease health care costs, more physician-employees, and less reluctance by younger physicians to utilize striking as a means of giving voice to discontent. The Affordable Care Act increases the number of patients needing care, whereas the cost of health care continues to increase at an unsustainable pace.54 More physicians now than ever before are employees. In 1983, 24% of US physicians were employees; this rose to 42% in 2012.55 Limited data suggest that younger physicians may be more likely to consider strikes as a potential negotiation tool. In a 2005 survey of thirdyear medical students, residents/fellows, and attending physicians at a single US academic center before an impending nursing strike, medical students were more likely to believe that strikes are sometimes necessary to achieve important goals (88%) compared with residents/fellows (69%) and attending physicians (43%).18 Surveys of medical students performed in countries with a nationalized health service found that most students felt that physicians should be allowed to strike. (85% of medical students in Croatia24 and 97% in Israel supported physician strikes.56) If younger physicians are more likely to be in support of the right of physicians to strike, then the use of strikes as a possible www.anesthesiaclinics.com
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USA38,39
France40–43
2001, 2002, 2005, 2012
Israel
2002-2003
1994, 2000, 2011
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Country
New Jersey—5 d strike W. Virginia—3 d strike Pennsylvania—Threatened strike Nevada—2 wk strike 2001-2002—7 mo night and weekend strike 2002—1 wk, gynecologists refuse to use ultrasound on pregnant women 2005—2 wk strike by EDs 2012—1 d strike
1994—1 d strike 2000—7 mo strike 2011—6 mo intermittent strikes
Actions Taken
Patient care 2002—Protest court ruling that gynecologist could be liable if a disabled child not picked up on prenatal ultrasound 2005—Health care reform to require private outpatient physicians to hold after-hours clinics Hire more staff to cope with 35-h work week legislation Working conditions More beds Limit work hours for trainees Salary and/or benefits Salary increase Protest limits on ability to charge fees higher than basic state tariffs
Patient care Allot more time per outpatient clinic visit Increase hospital capacity Work conditions Limit number of consecutive hours worked Reduce total number of hours worked Salary and/or benefits Increase salary Allow private practice in public hospitals Increase salary in rural areas to recruit more physicians to work in rural areas Pension changes Salary and/or benefits Protest rising malpractice insurance costs
Reasons for Strike
2002—Fee increase 2002—Law passed that would not allow lawsuit simply for being born 2005—Decree reorganizing on-call services through ED and private physicians; can requisition physicians if not enough volunteers
Tort reform bills passed in several states
Salary increased Limited number of consecutive hours worked 2000—10-year no strike agreement
Main Outcomes
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Year
Table 1. Summary of Select Physician Strikes Over the Past 20 Years
32 Li et al
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20 d strike
2 wk strike
1 d strike
2012—3 m strike 2014—Ongoing strike since March 8, 2014 Administrative strike—slow down of issuing essential medical documents
Costa Rica1
UK19,47
Egypt48–50
2011
2012
2012, 2014
2006—13 wk rolling strike by academic physicians 2006—8 wk rolling strike by public physicians 2012—1 d strike
South Africa46
Germany44,45
2010
2006, 2012
Work conditions Limit number of hours worked Salary and/or benefits Salary increase Fee increase Protest increase in required work hours without corresponding increase in salary Patient care Lack of vital medical equipment Salary and/or benefits Salary increase Work conditions Work hour restrictions Working conditions Limit work hours Adequate ventilation in operating rooms Salary and/or benefits Salary increase Salary and/or benefits Protest increase in doctor contributions to pensions and increased retirement age to 68 y Patient care Increase health care budget Increase number of ICU beds Salary and/or benefits Increase salary Work conditions Increase hospital security
Government considering flat pension contribution rate rather than tiered system 2012—Understanding that draft Staff Law would be passed with better working conditions, increase salary, but legislature disbanded before passage of law
Adequate ventilation in operating rooms More vacation days Salary increase
Salary increase
Salary increase Limited hours in a work week Fee increase
Ethics of Physician Strikes in Health Care
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South Korea39
2014
Nepal52
2014
India53
Bangladesh
2014
51
Protest police atrocity against physicians Patient care Protest introduction of telemedicine and for-profit hospitals Work conditions Limit work hours
1 d strike
Work conditions Increase hospital security Punish persons involved in attack on physicians Medical education reform—greater transparency and autonomy in state-run teaching hospitals
Reasons for Strike
5 d strike
5 d strike
2 d strike
Actions Taken
Police officer relative who was involved in assault withdrawn from position Promise of medical education reform—appointment of new dean, autonomy of state-run teaching hospital Person responsible arrested for attempted murder 6 m pilot of telemedicine Consulting group to monitor forprofit hospitals Work hour restrictions for trainees
Main Outcomes
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2014
Country
Year
Table 1. (continued)
34 Li et al
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negotiation tactic may occur more frequently in the future if other means of collective action are not successful. However, in order for strikes to be considered adequately justified, several elements should be in place: (1) adequate provisions for the health care of current patients, (2) potential for improvement of health care for future patients, and (3) no alternative to strike after repeated good-faith efforts at negotiation. All stakeholders, both employers (eg, government, health care organizations) and physicians, should recognize that they are negotiating for the long-term provision of best care for patients. Strikes should not be entered into lightly and may be seen as a failure for everyone at the negotiating table to keep the best interests of the patient at the center. ’
Case Conclusions
The group feels better prepared to reenter negotiations with the hospital armed with new tools and information that allows them to consider the possibility of a strike (with appropriate legal input). As the anesthesiologists consider reopening negotiations utilizing mediation, binding arbitration, or potentially job actions, they consider the following: How would we assure adequate care for our current patients during a strike? Would a strike improve the health of future patients enough that I can justify potential harm to current patients? Have we made enough good-faith efforts at negotiation?
The authors declare that they have nothing to disclose.
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References
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9. The Definition of “Supervisor” Under the National Labor Relations Act. February 1, 2008. Available at: http://congressionalresearch.com/RL34350/document.php. Accessed April 22, 2014. 10. When 10 Days Is Not 10 Days - The National Labor Relations Act’s Strike Notice Requirement in the Health Care Industry. 2003. Available at: http://www.jonesday. com/files/Publication/c1e2bc35-4acf-42c5-b59d-ee992a60ca4c/Presentation/Publication Attachment/ddf68290-9515-44f7-ac1d-d3c87b790418/10.Days.Not.10.Days_7-03.pdf. Accessed April 22, 2014. 11. Hirschman AO. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organization and States. Cambridge: Harvard University Press; 1970. 12. U.S. Department of Health and Human Services: Health Resources and Services Administration Bureau of Health Professions. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. December 2008. Available at: bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Accessed April 22, 2014.. 13. Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 14. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353: 1810–1818. 15. Bishop TF, Federman AD, Keyhani S. Declines in physician acceptance of medicare and private coverage. Arch Intern Med. 2011;171:1117–1119. 16. Olson M. The Logic of Collective Action Public Goods and the Theory of Groups. Cambridge, MA: Harvard University Press; 1971. 17. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med. 2003;138:839–841. 18. Li ST, Srinivasan M, Der-Martirosian C, et al. Developing personal values: trainees’ attitudes toward strikes by health care providers. Acad Med. 2011;86:580–585. 19. Fiester A. Physicians and strikes: can a walkout over the malpractice crisis be ethically justified?. Am J Bioethics. 2004;4:W12–W16. 20. World Health Organization. Constitution of the World Health Organization. 1948. Available at: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua = 1. Accessed April 10, 2014. 21. World Health Organization. Universal health coverage. Available at: http:// www.who.int/universal_health_coverage/en/. Accessed April 9, 2014. 22. Lockley SW, Barger L, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(suppl):7–18. 23. Doctors’ strike at 26 South African hospitals enters third week. Digital Journal April 24, 2009. Available at: http://www.digitaljournal.com/article/271489. Accessed April 24, 2014. 24. Hadzibegovic I, Danic A, Hren D. Medical students’ opinions on physicians’ strike: cross sectional questionnaire study. Croat Med J. 2004;45:63–66. 25. Kravitz RL, Shapiro MF. Duration and intensity of striking among participants in the Ontario, Canada doctors’ strike. Med Care. 1992;30:737–743. 26. Baer N. Despite some PR fallout, proponents say MD walkouts increase awareness and may improve health care. Can Med Assoc J. 1997;157:1268–1271. 27. Collective Bargaining, Work Stoppages, and Slowdowns. Available at: http://www. acep.org/Clinical—Practice-Management/Collective-Bargaining,-Work-Stoppages,and-Slowdowns/. Accessed April 22, 2014.. 28. Walsh B, Eskin B, Allegra J, et al. The effects of a physician slowdown on emergency department volume and treatment. Acad Emerg Med. 2006;13:1242–1245. 29. Crocker K, Cramer B, Hutchinson JM. Antibiotic availability and the prevalence of pediatric pneumonia during a physicians’ strike. Can J Infect Dis Med Microbiol. 2007;18:189–192. www.anesthesiaclinics.com
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30. Harvey M, Al Shaar M, Cave G, et al. Correlation of physician seniority with increased emergency department efficiency during a resident doctors’ strike. N Z Med J. 2008;121:59–68. 31. Salazar A, Corbella X, Onaga H, et al. Impact of a resident strike on emergency department quality indicators at an urban teaching hospital. Acad Emerg Med. 2001;8:804–808. 32. Cunningham SA, Mitchell K, Narayan KM, et al. Doctors’ strikes and mortality: a review. Soc Sci Med. 2008;67:1784–1788. 33. Pantell RH, Irwin CE. Appendectomies during physicians’ boycott. Analysis of surgical care. JAMA. 1979;242:1627–1630. 34. UP doctors on strike, 8 more die. The Times of India, March 5, 2014. Available at: http://timesofindia.indiatimes.com/india/UP-doctors-on-strike-8-more-die/articleshow/ 31436019.cms. Accessed April 22, 2014. 35. Bhuiyan MM, Machowski A. Impact of 20-day strike in Polokwane Hospital (18 August - 6 September 2010). S Afr Med J . 2012;102:755–756. 36. Barnoon S, Carmel S, Zalcman T. Perceived health damages during a physicians’ strike in Israel. Health Serv Res. 1987;22:141–155. 37. Weil LG, Nun GB, McKee M. Recent physician strike in Israel: a health system under stress?. Isr J Health Policy Res. 2013;2:33. 38. Hellinger FJ, Encinosa WE. The impact of state laws limiting malpractice damage awards on health care expenditures. Am J Public Health. 2006;96:1375–1381. 39. Doctors’ strike is avoided by pact. Korea JoongAng Daily, March 18, 2014. Available at: http://koreajoongangdaily.joins.com/news/article/Article.aspx?aid = 2986526. Accessed April 24, 2014. 40. Spurgeon B. French doctors go on strike to demand reintroduction of compulsory out of hours work. BMJ. 2005;330:864. 41. Scan strike by French doctors. BBC News, January 3, 2002. Available at: http:// news.bbc.co.uk/2/hi/health/1740380.stm. Accessed April 24, 2014. 42. France Bans Damages for’Wrongful Births’. January 11, 2002. Available at: http:// www.nytimes.com/2002/01/11/world/france-bans-damages-for-wrongful-births.html. Accessed April 28, 2014. 43. Durand de Bousingen D. New French government solves doctors’ longstanding grievances. Lancet. 2002;359:2258. 44. Janus K, Amelung VE, Gaitanides M, et al. German physicians “on strike”—shedding light on the roots of physician dissatisfaction. Health Policy. 2007;82:357–365. 45. Nowak D. Doctors on strike—the crisis in German health care delivery. N Engl J Med. 2006;355:1520–1522. 46. South Africa Unions’ Strike Suspended. The New York Times, September 6, 2010. Available at: http://www.nytimes.com/2010/09/07/world/africa/07safrica.html?_r = 0. Accessed April 24, 2014. 47. UK doctors strike despite $105,000-a-year pension offer. NBC News, World News, June 21, 2012. Available at: http://worldnews.nbcnews.com/_news/2012/06/21/12335114-ukdoctors-strike-despite-105000-a-year-pension-offer?lite. Accessed April 18, 2014. 48. Egypt doctors to go on’administrative strike’. Ahram Online, 2014. Available at: http://english.ahram.org.eg/NewsContent/1/64/99001/Egypt/Politics-/Egypt-doctorsto-go-on-administrative-strike.aspx. Accessed April 18, 2014. 49. Kortam H. Egypt doctors to go on ‘administrative’ strike. Daily News Egypt. January 1, 2014 Available at: http://www.dailynewsegypt.com/2014/01/01/egypts-doctorsstrike-for-one-day/. Accessed April 18, 2014. 50. Shukla S. Violence against doctors in Egypt leads to strike action. Lancet. 2012;380:1460. 51. Birdem doctors call off strike. The Daily Star, April 16, 2014. Available at: http:// www.thedailystar.net/birdem-doctors-call-off-strike-20251. Accessed April 18, 2014. www.anesthesiaclinics.com
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52. Nepal doctor strike leaves thousands without care. Medicalxpress, January 20, 2014. Available at: http://medicalxpress.com/news/2014-01-nepal-doctor-thousands.html. Accessed April 18, 2014. 53. UP doctors’ strike: Solank booked for rioting. The Hindu, March 7, 2014. Available at: http://www.thehindu.com/news/national/other-states/up-doctors-strike-solankibooked-for-rioting/article5761220.ece. Accessed April 18, 2014. 54. National Center for Chronic Disease Prevention and Health Promotion - Division of Population Health - Centers for Disease Control and PreventionRising Health Care Costs are Unsustainable. Available at: http://www.cdc.gov/workplacehealthpromotion/ businesscase/reasons/rising.html. Accessed April 22, 2014. 55. Kane CK, Emmons DW. Policy research perspectives: new data on physician practice arrangements: private practice remains strong despite shifts toward hospital employment. Am Med Assoc Available at: http://download.ama-assn.org/resources/ doc/health-policy/x-pub/prp-physician-practice-arrangements.pdff. Accessed April 20, 2014. 56. Lachter J, Lachter L, Beiran I. Attitudes of medical students to a physicians’ strike. Med Teach. 2007;29:411.
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Su-Ting T. Li, MD, MPH Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, California
Malathi Srinivasan, MD Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
Richard L. Kravitz, MD, MSPH Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
Michael S. Wilkes, MD, MPH, PhD Department of Internal Medicine, University of California Davis, School of Medicine, Sacramento, California
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Case
Anesthesiologists employed by a large regional medical center in the United States have been in contract negotiations with the hospital administration for the last 6 months. Negotiations appear to have stalled. The hospital claims the anesthesiologists’ demands for higher salary and more vacation time are unreasonable: “They just want more money.” The anesthesiologists claim they want safer working conditions: “Being on-call 24 hours at a time is unsafe. I am not as alert at 3 AM when I have been up since 5 AM the day prior.” A practice partner recalls an anesthesiology strike in Costa Rica in 2011 in which the hospital claimed the anesthesiologists wanted more money, whereas the anesthesiologists stated that they wanted better operating room ventilation and safety measures.1 He suggests that the group consider striking. The US anesthesiologists in the stalled contract negotiations consider the following questions: (1) Is it legal for physicians to strike? (2) Is it ethical for physicians to strike? (3) How should physicians ensure individual patient welfare during a strike? REPRINTS: SU-TING T. LI, MD, MPH, DEPARTMENT OF PEDIATRICS, UNIVERSITY OF CALIFORNIA DAVIS, SCHOOL MEDICINE, 2516 STOCKTON BLVD, SACRAMENTO, CA. E-MAIL: [email protected]
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INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 53, Number 3, 25–38 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
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(4) Have physician strikes been successful? (5) Should I, personally, go on strike? ’
Background
Physician strikes have been relatively rare in the United States. However, recent changes in the health care landscape and societal expectations may lead more physicians to consider job actions, including strikes. As the health care marketplace in the United States consolidates, more physicians are being employed by large health care organizations.2 As a result, physician autonomy has diminished, and more physicians find themselves negotiating over their conditions of work with large health systems or insurance plans. As professionals, physicians have previously enjoyed a great deal of autonomy, including self-governance of their own profession, selection of who gains entry into that profession, independent decision making, and assessment of what constitutes fair reimbursement. As employees, rather than self-employed practice owners, physicians are seeing their autonomy challenged and their salaries and benefits dictated by others. They are often expected to see more patients, and the care they provide, such as the length of visits, may be constrained by the dictates of their employer.3 As more physicians move from being self-employed, autonomous professionals to contract employees, physicians find themselves faced with the same concerns that employees have faced since the start of the industrial age: negotiation for fair wages, benefits, and safe work conditions.4 In addition, physicians have the added privilege and fiduciary responsibility of advocating for the best interest of their patients.5 For physicians, strikes create an ethical tension between a duty to provide care for current patients versus striking to advocate for better care for future patients through system improvements (improving safety, equity, quality of care, pipeline of future physicians). This ethical tension is further intensified when the public perceives the strike would result in personal gain for physicians (improved salary, better benefits, lower malpractice costs, or more vacation time) at the expense of potential harm to the patient through lack of immediate care. This paper explores the ethics of physician strikes in health care. We discuss collective bargaining laws in the United States, the ethics of physician strikes, the modern history of physician strikes, and the potential future of physician strikes. Collective Bargaining—Is it Legal for Physicians to Strike?
Strikes, or work stoppages, originated during the industrial age as more people moved from being autonomous workers to salaried www.anesthesiaclinics.com
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employees wherein their workplace, wages, working conditions, and employment were dependent on others. Groups of workers shared common concerns for welfare and well-being, which drove them toward unionization and then collective bargaining. Job actions, including strikes and work slowdowns, emerged as an approach unions used to promote negotiation with their employers when all else failed. The effectiveness of a strike was greatest when work disruption resulted in economic pain for the employer, even when the strike would temporarily adversely affect the individuals striking as well. The United Nations’ Universal Declaration of Human Rights contends that “everyone has the right to form and join trade unions for the protection of his interests”; “everyone who works has the right to just and favorable remuneration”; and “everyone has the right to freedom of peaceful assembly” and “the right to freedom of opinion and expression.”6 Some have interpreted this as physicians having the same rights as other employees—to collectively bargain and protest and a right to strike should negotiations fail.7,8 In the United States, collective bargaining by employees did not have a strong legal basis until the National Labor Relations Act (NLRA) of 1935; until then labor organizers had been potentially subject to prosecution for violating antitrust and racketeering laws. The NLRA provides the policy framework around which groups of employees may collectively negotiate with their employer. Physicians who are independent contractors or supervisors (exercise independent judgment to assign responsibilities and direct other employees at least 10% to 15% of the time)9 are not covered by the NRLA.9 Health care workers who fall under NLRA may legally unionize, engage in collective bargaining, and strike with a 10-day written advance notice.10 Dissatisfied employees have 2 major options—they may “exit” or give “voice” to their concerns.11 Physicians, in particular, may “exit” by choosing to practice elsewhere, limiting the type or number of patients they care for, leaving their profession, or not entering it in the first place.12 This “exit” may be reflected in the type of employer for whom a physician works (profit vs. nonprofit, religious vs. secular, government vs. private), the specialties that physicians choose to train in,13 the countries or regions in which they practice,12,14 the types of insurance (public or private) they choose to accept,15 how much clinical time they practice (vs. conducting research or performing administrative duties), and their chosen age of retirement.12 Alternatively, physicians may give “voice” to their concerns individually or collectively. Individually, physicians may choose to complain to elected officials, write letters to the editor, and contribute to political campaigns or action committees. If they find individual action inadequate, they may choose to collectively protest, lobby, or use their collective bargaining to negotiate. If collective bargaining is not www.anesthesiaclinics.com
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effective, they may seek mediation, binding arbitration, or as a last resort, conduct job actions such as sick-outs, slowdowns, and strikes.16
Strikes and Medical Professionalism—Is it Ethical for Physicians to Strike?
Typically, physician strikes result in the temporary cessation of usual patient care activities. For some, physician withdrawal from patient care challenges traditional ideas about medical professionalism and professional standards. The Physician Charter on Medical Professionalism, endorsed by >130 physician organizations worldwide, defines 3 guiding principles at the heart of medical professionalism: (1) primacy of patient welfare, (2) patient autonomy, and (3) social justice.5,17 The principles of patient welfare and social justice are often considered when discussing the ethics of strikes. For some physicians, patient welfare is the overriding principle making the thought of any strike unethical and indeed unthinkable.18,19 For others, this principle extends to the welfare of future patients and may pair with the principle of social justice to allow physicians to be open to the possibility of strikes depending on the circumstances and the potential for positive future change.18 Social justice is an underlying principle of the World Health Organization (WHO), which in 1948 declared health a fundamental human right.20 Since that time, the WHO has recognized that to achieve the goal of universal health coverage, several factors are needed, including a “strong, efficient, well-run health system,” “a system for financing health services,” “access to essential medicines and technologies,” and “a sufficient capacity of well-trained, motivated health workers.”21 As access to health care is expanded for a larger percent of the population there may be a tendency to centralize systems for financing health services to maximize efficiency. There will also be new guidelines and rules to govern practice, which may not be agreed to in parts of the medical community. Within the United States, there are potential conflicts between health care institutions, insurers, specialty groups, and government oversight groups. Each may argue in the public arena that their goal is to promote patient welfare, whereas others argue that the same goal is primarily self-serving and protectionist. At times, advocating for “best care” for future patients may mean compromising on “best care” for current patients. There are already precedents for this. For example, renovating old facilities or replacing outdated equipment may improve the ability to care for patients in the future, but may temporarily reduce capacity to care for patients during the renovation or delay care during the transition from old to new equipment. Transitioning to an electronic health record may lead to an increase in communication between providers, but may temporarily lead to fewer patients being seen as providers learn the new system. www.anesthesiaclinics.com
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When physician strikes are considered, the issues are often murky. Physician strikes frequently have overlapping patient welfare–centered goals (ie, patient safety, safe working conditions), social justice–centered goals (ie, access or population health), and profession-centered goals (ie, wages and benefits). Unsafe working conditions not only affect physician health and well-being, but may also affect care of both current and future patients. Working too many consecutive hours may jeopardize the safety of current patients if sleep-deprivation impairs clinical judgment.22 Increased security in hospitals would improve safety for staff and for patients. Some may argue that at some point, by neglecting to advocate for fair wages and working conditions, medicine loses the ability to attract and retain a “sufficient capacity of well-trained, motivated health workers”21 as required by the WHO to realize universal health coverage. For example, a study by the South African Medical Association estimated that government doctors in South Africa are underpaid by 50% to 75%; in turn, South Africa has a 30% medical staff shortage.23 Strike context is an important factor when health care workers consider whether or not a strike is personally ethical. Medical students, residents/fellows, and physicians are more likely to support strikes related to patient care or work conditions than strikes related to salary.18,24 A 2005 survey in a single US medical center found that medical students were more likely to support physician strikes for patient care issues (71%) and work conditions (68%) than salary (43%).18 Although the pattern was similar in faculty physicians, fewer faculty physicians supported physician strikes for any reason, with 44% supporting strikes for patient care issues, 42% for work conditions, and 20% for salary issues. As physicians balance the welfare of their present patients against that of future patients, protesting unsafe working conditions and lack of equipment, and, potentially, deterioration of respect and poor compensation driving potential future physicians into other fields, job actions may move from unthinkable to an important means to negotiate essential changes. How Should Physicians Ensure Individual Patient Welfare During a Strike?
For many physicians, the decision of whether to strike involves weighing the likelihood of a strike’s achieving its objectives against the potential harm that a strike may cause. As health care is an essential service, a traditional strike with full withdrawal of physician services could considerably harm patients. To minimize patient harm, striking physicians often exercise substantial discretion in the intensity and duration of withdrawal of patient services.25 Although some have argued that physician withdrawal of services is not unusual (eg, when www.anesthesiaclinics.com
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they go on vacation, are sick, retire, or move away),26 there is usually planned physician coverage when this occurs. This may not be available during a strike. Therefore, even ardent supporters of health care strikes argue that strikes need contingency plans to care for the sickest patients, including providing emergent/urgent surgeries and emergency care.27 Good contingency plans mitigate the impact of a strike on current patients. When outpatient physicians strike, emergency department utilization increases during the period of the strike. A 2003 work slowdown of outpatient physicians in New Jersey resulted in a 79% increase in total patient volume seen in the emergency department and a 223% increase in pediatric volume.28 An outpatient physician strike in Canada in 2002 led to a decrease in outpatient antibiotic prescribing for pediatric pneumonia but no change in incidence of radiographically diagnosed pneumonia in the emergency department during the strike, indicating that the sickest patients were still able to receive timely care.29 In some circumstances, striking may have no short-term effects on measurable mortality rates. Strikes of resident physicians-in-training often lead to no change in mortality because faculty physicians assume care.30 Studies in emergency departments during resident strikes found that both quality of care31 and efficiency30 increased during a resident strike because faculty physicians, with more experience, assumed the care of patients. A review of the impact of physician strikes between 1976 and 2003 on patient mortality found a decrease in overall mortality during the period of strikes because of a decrease in numbers of elective surgeries during the period of the strike; emergent surgeries were still performed.32 No changes in the quality of emergency care, such as appendectomy care, were noted.33 The lack of increase in mortality seen is likely due to both the length of the strikes (with potentially longer strikes leading to more negative outcomes) and the thoughtful contingency planning to care for patients with emergent and urgent conditions (which would not be seen with a complete withdrawal of services). Recent strikes with complete withdrawal of services have led to patient deaths.34 However, adverse consequences of physician strikes may be seen even with the best-laid contingency plans, particularly as the length of the strike increases. A 20-day physician strike in South Africa in 2010 was associated with fewer patients admitted to the hospital and lower overall mortality, but a higher mortality rate of the patients who were emergently admitted.35 The longer the duration of the strike, the more difficult it is for health care contingency plans to provide adequate care to the population. In a 118-day physician strike in Israel in 1983, patients, particularly those with limited access to health care choices, perceived the strike damaged their health despite the establishment of alternative care centers and availability of emergency rooms to minimize potential harm to patients during the strike.36 www.anesthesiaclinics.com
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Modern History of Physician Strikes—Have Physician Strikes Been Successful?
Withdrawal or cessation of clinical services (striking) is the most extreme form of collective action. Physician strikes over the past 20 years have varied in purpose and success (Table 1). Health care provider strikes may have a negative impact on health care providers overall, if the public does not support the rationale surrounding the strike or if patient harm results from the strike. This negative public view increases if the strike is considered primarily physician welfare–centered rather than patient welfare-centered.2,25,36 Physicians, even when employed, are usually high wage earners, relative to the average wage earner. Yet, the practice of medicine is tightly regulated. Professionals in less tightly regulated fields have the ability to increase or decrease their professional fees more easily. A strong negative reaction was seen during the Ontario, Canada strike in 1986. In this strike, physicians went on a 23-day strike to try to prevent a federal ban on “extra-billing” (charging more than the amount payable by the Ontario Health Insurance Plan for providing an insured service). The strike failed to prevent the ban from going into law, and it also alienated the public.25 Looking Toward the Future of Strikes in Health Professionals—Should I Strike?
The interplay of several factors may impact the frequency of health care strikes: increasing health care needs paired with the need to decrease health care costs, more physician-employees, and less reluctance by younger physicians to utilize striking as a means of giving voice to discontent. The Affordable Care Act increases the number of patients needing care, whereas the cost of health care continues to increase at an unsustainable pace.54 More physicians now than ever before are employees. In 1983, 24% of US physicians were employees; this rose to 42% in 2012.55 Limited data suggest that younger physicians may be more likely to consider strikes as a potential negotiation tool. In a 2005 survey of thirdyear medical students, residents/fellows, and attending physicians at a single US academic center before an impending nursing strike, medical students were more likely to believe that strikes are sometimes necessary to achieve important goals (88%) compared with residents/fellows (69%) and attending physicians (43%).18 Surveys of medical students performed in countries with a nationalized health service found that most students felt that physicians should be allowed to strike. (85% of medical students in Croatia24 and 97% in Israel supported physician strikes.56) If younger physicians are more likely to be in support of the right of physicians to strike, then the use of strikes as a possible www.anesthesiaclinics.com
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USA38,39
France40–43
2001, 2002, 2005, 2012
Israel
2002-2003
1994, 2000, 2011
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Country
New Jersey—5 d strike W. Virginia—3 d strike Pennsylvania—Threatened strike Nevada—2 wk strike 2001-2002—7 mo night and weekend strike 2002—1 wk, gynecologists refuse to use ultrasound on pregnant women 2005—2 wk strike by EDs 2012—1 d strike
1994—1 d strike 2000—7 mo strike 2011—6 mo intermittent strikes
Actions Taken
Patient care 2002—Protest court ruling that gynecologist could be liable if a disabled child not picked up on prenatal ultrasound 2005—Health care reform to require private outpatient physicians to hold after-hours clinics Hire more staff to cope with 35-h work week legislation Working conditions More beds Limit work hours for trainees Salary and/or benefits Salary increase Protest limits on ability to charge fees higher than basic state tariffs
Patient care Allot more time per outpatient clinic visit Increase hospital capacity Work conditions Limit number of consecutive hours worked Reduce total number of hours worked Salary and/or benefits Increase salary Allow private practice in public hospitals Increase salary in rural areas to recruit more physicians to work in rural areas Pension changes Salary and/or benefits Protest rising malpractice insurance costs
Reasons for Strike
2002—Fee increase 2002—Law passed that would not allow lawsuit simply for being born 2005—Decree reorganizing on-call services through ED and private physicians; can requisition physicians if not enough volunteers
Tort reform bills passed in several states
Salary increased Limited number of consecutive hours worked 2000—10-year no strike agreement
Main Outcomes
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Year
Table 1. Summary of Select Physician Strikes Over the Past 20 Years
32 Li et al
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20 d strike
2 wk strike
1 d strike
2012—3 m strike 2014—Ongoing strike since March 8, 2014 Administrative strike—slow down of issuing essential medical documents
Costa Rica1
UK19,47
Egypt48–50
2011
2012
2012, 2014
2006—13 wk rolling strike by academic physicians 2006—8 wk rolling strike by public physicians 2012—1 d strike
South Africa46
Germany44,45
2010
2006, 2012
Work conditions Limit number of hours worked Salary and/or benefits Salary increase Fee increase Protest increase in required work hours without corresponding increase in salary Patient care Lack of vital medical equipment Salary and/or benefits Salary increase Work conditions Work hour restrictions Working conditions Limit work hours Adequate ventilation in operating rooms Salary and/or benefits Salary increase Salary and/or benefits Protest increase in doctor contributions to pensions and increased retirement age to 68 y Patient care Increase health care budget Increase number of ICU beds Salary and/or benefits Increase salary Work conditions Increase hospital security
Government considering flat pension contribution rate rather than tiered system 2012—Understanding that draft Staff Law would be passed with better working conditions, increase salary, but legislature disbanded before passage of law
Adequate ventilation in operating rooms More vacation days Salary increase
Salary increase
Salary increase Limited hours in a work week Fee increase
Ethics of Physician Strikes in Health Care
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South Korea39
2014
Nepal52
2014
India53
Bangladesh
2014
51
Protest police atrocity against physicians Patient care Protest introduction of telemedicine and for-profit hospitals Work conditions Limit work hours
1 d strike
Work conditions Increase hospital security Punish persons involved in attack on physicians Medical education reform—greater transparency and autonomy in state-run teaching hospitals
Reasons for Strike
5 d strike
5 d strike
2 d strike
Actions Taken
Police officer relative who was involved in assault withdrawn from position Promise of medical education reform—appointment of new dean, autonomy of state-run teaching hospital Person responsible arrested for attempted murder 6 m pilot of telemedicine Consulting group to monitor forprofit hospitals Work hour restrictions for trainees
Main Outcomes
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2014
Country
Year
Table 1. (continued)
34 Li et al
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negotiation tactic may occur more frequently in the future if other means of collective action are not successful. However, in order for strikes to be considered adequately justified, several elements should be in place: (1) adequate provisions for the health care of current patients, (2) potential for improvement of health care for future patients, and (3) no alternative to strike after repeated good-faith efforts at negotiation. All stakeholders, both employers (eg, government, health care organizations) and physicians, should recognize that they are negotiating for the long-term provision of best care for patients. Strikes should not be entered into lightly and may be seen as a failure for everyone at the negotiating table to keep the best interests of the patient at the center. ’
Case Conclusions
The group feels better prepared to reenter negotiations with the hospital armed with new tools and information that allows them to consider the possibility of a strike (with appropriate legal input). As the anesthesiologists consider reopening negotiations utilizing mediation, binding arbitration, or potentially job actions, they consider the following: How would we assure adequate care for our current patients during a strike? Would a strike improve the health of future patients enough that I can justify potential harm to current patients? Have we made enough good-faith efforts at negotiation?
The authors declare that they have nothing to disclose.
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References
1. More doctors walking off the job. 2011. Available at: http://www.ticotimes.net/2011/ 12/02/more-doctors-walking-off-the-job. Accessed April 16, 2014. 2. Jackson RL. Physician strikes and trust. Camb Q Healthc Ethics. 2000;9:504–512. 3. Collective Bargaining/Antitrust Relief. Available at: http://lobby.la.psu.edu/081_ Physician_Antitrust_Waiver/Organizational_Statements/American_Medical_Association/ AMA_Collective_Bargaining_Antitrust_Relief_AMA_Policy.htm. Accessed April 22, 2014. 4. Thompson SL, Salmon JW. Strikes by physicians: a historical perspective toward an ethical evaluation. Int J Health Serv. 2006;36:331–354. 5. Medical Professionalism Project. Medical professionalism in the new millennium: a physicians’ charter. Lancet. 2002;359:520–522. 6. United Nations. The Universal Declaration of Human Rights. Available at: http:// www.un.org/en/documents/udhr/. Accessed April 10, 2014. 7. Abbasi IN. Protest of doctors: a basic human right or an ethical dilemma. BMC Med Ethics. 2014;15:24. 8. Chima SC. Global medicine: is it ethical or morally justifiable for doctors and other healthcare workers to go on strike?. BMC Med Ethics. 2013;14(suppl 1):S5. www.anesthesiaclinics.com
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9. The Definition of “Supervisor” Under the National Labor Relations Act. February 1, 2008. Available at: http://congressionalresearch.com/RL34350/document.php. Accessed April 22, 2014. 10. When 10 Days Is Not 10 Days - The National Labor Relations Act’s Strike Notice Requirement in the Health Care Industry. 2003. Available at: http://www.jonesday. com/files/Publication/c1e2bc35-4acf-42c5-b59d-ee992a60ca4c/Presentation/Publication Attachment/ddf68290-9515-44f7-ac1d-d3c87b790418/10.Days.Not.10.Days_7-03.pdf. Accessed April 22, 2014. 11. Hirschman AO. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organization and States. Cambridge: Harvard University Press; 1970. 12. U.S. Department of Health and Human Services: Health Resources and Services Administration Bureau of Health Professions. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. December 2008. Available at: bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Accessed April 22, 2014.. 13. Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 14. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005;353: 1810–1818. 15. Bishop TF, Federman AD, Keyhani S. Declines in physician acceptance of medicare and private coverage. Arch Intern Med. 2011;171:1117–1119. 16. Olson M. The Logic of Collective Action Public Goods and the Theory of Groups. Cambridge, MA: Harvard University Press; 1971. 17. Blank L, Kimball H, McDonald W, et al. Medical professionalism in the new millennium: a physician charter 15 months later. Ann Intern Med. 2003;138:839–841. 18. Li ST, Srinivasan M, Der-Martirosian C, et al. Developing personal values: trainees’ attitudes toward strikes by health care providers. Acad Med. 2011;86:580–585. 19. Fiester A. Physicians and strikes: can a walkout over the malpractice crisis be ethically justified?. Am J Bioethics. 2004;4:W12–W16. 20. World Health Organization. Constitution of the World Health Organization. 1948. Available at: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua = 1. Accessed April 10, 2014. 21. World Health Organization. Universal health coverage. Available at: http:// www.who.int/universal_health_coverage/en/. Accessed April 9, 2014. 22. Lockley SW, Barger L, Ayas NT, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(suppl):7–18. 23. Doctors’ strike at 26 South African hospitals enters third week. Digital Journal April 24, 2009. Available at: http://www.digitaljournal.com/article/271489. Accessed April 24, 2014. 24. Hadzibegovic I, Danic A, Hren D. Medical students’ opinions on physicians’ strike: cross sectional questionnaire study. Croat Med J. 2004;45:63–66. 25. Kravitz RL, Shapiro MF. Duration and intensity of striking among participants in the Ontario, Canada doctors’ strike. Med Care. 1992;30:737–743. 26. Baer N. Despite some PR fallout, proponents say MD walkouts increase awareness and may improve health care. Can Med Assoc J. 1997;157:1268–1271. 27. Collective Bargaining, Work Stoppages, and Slowdowns. Available at: http://www. acep.org/Clinical—Practice-Management/Collective-Bargaining,-Work-Stoppages,and-Slowdowns/. Accessed April 22, 2014.. 28. Walsh B, Eskin B, Allegra J, et al. The effects of a physician slowdown on emergency department volume and treatment. Acad Emerg Med. 2006;13:1242–1245. 29. Crocker K, Cramer B, Hutchinson JM. Antibiotic availability and the prevalence of pediatric pneumonia during a physicians’ strike. Can J Infect Dis Med Microbiol. 2007;18:189–192. www.anesthesiaclinics.com
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