Is physician unionization a help or hindrance?

Both internal and external factors affect a physician’s work environment. Sometimes, these culminate in a loss of autonomy, thereby contributing to burnout. To reclaim this lost power, some employed physicians are joining or forming unions so that, via collective bargaining, they can attempt to negotiate better practice conditions.

Now, the question we need to consider is: Is unionization the solution to, or an exacerbation of, the problem?

Just over three-quarters of physicians in the United States are currently employed, and with employment comes a natural lack of control. Healthcare systems have processes and procedures in place that can impact one’s medical decision-making; for example, through a restricted medication formulary.

Plus, healthcare is governed by a multitude of state and federal laws and rules. Collectively, this weighs heavily on bedside physicians, who are taught to be the singular captain of the healthcare team, as they can no longer make many decisions absent from some level of employer influence. Burnout, emotional exhaustion and surrender sometimes ensue.

Enter physician unions

When physicians feel they are losing their autonomy, it is only natural to look for someone (or some group) to more adequately represent their interests and be a powerful voice to advocate for them. Enter physician unions—with the promise of reclaiming some control for the employed physician through negotiation, mediation or even a strike, the union offers much to those starving for a morsel of self-autonomy. But is this the best solution to the problem?

Unions are governed by the National Labor Relations Act (NLRA) and work by organizing a group of similar employees. A union’s communal power is in its purported unified voice, hence called a collective bargaining unit. Along with the act came the National Labor Relations Board (NLRB), “an independent federal agency that protects the rights of private sector employees to join together, with or without a union, to improve their wages and working conditions.”

In 2025, about 8% of physicians claimed to be unionized. This represents approximately 70,000 physicians, and the number of unionized physicians continues to grow. In comparison, about 20% of residents are unionized. The ability of residents and fellows to unionize was affirmed in 1999 under the NLRA, as they were deemed statutory employees.

Upsides of unions

Traditionally, unions act as the representative for a group. A union negotiates for its members and divides employees into labor (typically, the employee seeking representation) and management (those in supervisory roles, although not only at the highest levels). A supervisor can be an attending physician supervising a resident, a medical director of a physician group or a C-suite executive, for example.

Through contract negotiations, the union can advocate for improved working hours, safer workplace environments, more appropriate staffing ratios, higher compensation and benefit packages and greater job security through due process and protection from unjust termination as it serves as the collective, unified voice of representation.

In 2025, the JAMA Network published a research study which demonstrated that surveyed residents were supportive of unionization and thought that having such collective bargaining power would result in better pay and work hours. Unfortunately, a recognized limitation of this paper was the confirmation of those outcome measures.

I personally was a member of my resident union. I rose to become first its chair and then the southern regional vice president for the union at the national level. Still, I believe unions have pros and cons.

Downsides of unions

Many look to unions to represent them, when in fact the unions out there are really more representative of themselves and the many others who form the union. Those under the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO) umbrella, which encompasses the vast majority of unions, have extreme state and federal political positions that may not resonate with the bedside clinician who is wholly unaware that their dues are being used to support and fund those efforts extraneous to the reason they joined the union.

Unions can be a stifling muzzle in communicating with one’s direct superiors, typically require 1-3% of gross salary for membership dues and fees, are potentially viewed by the public as negative during strikes that may erode patient trust, limit individual flexibility in work arrangements, create a potentially contentious work environment hindering collaboration and are not always effective.

Regarding effectiveness, a recent survey of around 5,700 surgical residents in 285 programs found that unionized programs were more likely to offer more vacation time and housing stipends, but that there was no difference in work hour violations, educational environment or burnout between unionized and ununionized programs.

When negotiations falter or fail between the union and the employer, a strike may be considered. In healthcare specifically, law governs the provision of advanced notice to minimize the adverse impact on patient care. NLRA Section 8(g) states that, “before engaging in any strike, picketing or other concerted refusal to work at any healthcare institution,” the union must provide at least 10 days’ written notice that indicates the date and time of commencement.

This notice must be sent to the employer and the Federal Mediation and Conciliation Service. The time frame begins once the notice is received by both. In consideration of participating in a strike, physicians must balance the ethical duty to patient care, their current work environment and how the strike will be perceived by the public. A physician who goes on strike for increased wages may not be seen favorably by the public.

Many unions that represent physicians are part of a larger contingent, representing many other nonphysician and/or nonhealthcare employees. Unions have to balance the needs of their diverse members—at times, accomplishing what physicians want is not of primary concern to union leaders.

Further, individual unions have their own political platforms and agendas and have taken public and vocal stances on controversial issues. Joining a union is much more than seeking adequate representation to reclaim control of a local practice setting or addressing some individual employment issue; it is also joining a much larger universe that may not represent your interests fully and may publicly take stances that you disagree with.

Proceed thoughtfully

Careful consideration should be employed when deciding whether to join or create a physician union. What may work for some may not work for others. In the end, as research has found, medical trainees need to be and feel valued. They should be able to partner with their hospital employers to achieve the work environment they seek, including autonomy, experiential learning and academic time.

The same can be said for all employed physicians, regardless of employer. Physicians need high-level representation—as such, physician executives should not be seen as exchangeable commodities, but rather as integral components of a healthcare system, and those nonphysician leaders at the helm would do well to heed the doctors’ advice to provide a positive healthcare system for their employees.

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