So first and foremost, thank you all so much for joining us this evening for our National Grand Rounds series. This evening, our topic is unionization in healthcare and its impact on physicians of physiatrists experience. And this evening, our faculty is Dr. Matthew Bartels, as well as our moderator, Dr. Rita Hamilton. And just going to briefly talk through some housekeeping slides. First and foremost, this activity is being recorded and it will be made available on the Academy's online learning portal. For the best attendee experience during this activity, please be sure to mute your microphone when you're not speaking. You're also invited and encouraged to keep your camera on and make sure to select hide non-video participants. So this will ensure that speakers are prominent on your screen. And then to ask a question, please be sure to use the raise your hand feature and unmute if you're called upon, or use the chat feature to type your question. And we just like to note that time may not permit the panel to field every question, but we will do our best to address every question. And then just a little bit about some of our Zoom features here. So we have our unmute and start video options. We also have our chat feature here. This is where you can enter a question or a comment. And then if you have any reactions, feel free to place those there in the reactions option. And then just some more additional options here to unmute your audio, start video. And this is where you can find that hide non-video participants section. And then just a bit about our agenda this evening. So after these slides, we will touch or we will move forward with our introductions and then we will go through our presentation and save about 15 minutes at the end for our question and answer portion. And then I will pass this off to Dr. Hamilton. Hey, thank you, Sammy. As from the Academy, we just want to remind everyone that this presentation is meant to be an informal session about unionization and really directed at sharing one's physiatrist or physiatrist experience on this journey. The Academy does not have any stance on being for or against unionization and is in no way sharing this information to tell anyone how to unionize. So if you have comments or questions, respectful participation is encouraged and welcome. And so like Sammy said, I am Rita Hamilton, Baylor University Medical Center and Baylor Scott and White Institute for Rehabilitation. And I'm so excited to be joined and moderating for Dr. Matthew Bartels tonight. Dr. Bartels is the chairman of the Department of Rehabilitation Medicine at Montefiore Health System, Albert Einstein College of Medicine. He received his MD and MPH degree from Columbia College of Physicians and Surgeons and trained in internal medicine and rehabilitation medicine at Columbia Presbyterian Medical Center in New York. He established the Human Performance Laboratory at Columbia University and directed the Cardiopulmonary Rehabilitation Team there until September of 2013, when he assumed the chairmanship role at Montefiore Health System. Dr. Bartels has published multiple scientific reviews and papers, chapters, and has been invited to speak both in the United States and internationally. His areas of interest include cardiopulmonary rehabilitation, heart and lung transplantation rehabilitation, biomechanical intervention for musculoskeletal pain, exercise and cognitive development of new models of post-acute care delivery and international rehabilitation. His most recent research is on exercise and improving social function and cognition in schizophrenia and access to rehabilitation services in the international setting. Dr. Bartels, on behalf of the Academy, we appreciate you so much for providing us our grand rounds this evening and thank you, and I will turn it over to you. All right, Dr. Hamilton, thank you so much for that introduction. I'm going to be doing this as really an opportunity to discuss some experience on labor organization in medicine and as well to share a little bit of history of labor organization because it's important for people to have that understanding in order to be able to really be able to look at what's going on in medicine. Disclosures, I don't really have any related to this talk. I'm not involved in labor organization. I'm not involved in labor relations, although I have negotiated with unions, but that's basically it. It's interesting, though, that I did not realize until being asked to do this how my experience was rather unusual, I think, among most healthcare practitioners and that I have always, since my training, worked in a unionized healthcare environment, and so what seems normal to me may actually be of interest and very different from the experience others have been experiencing. So topics we'll cover. I'm going to look a little bit at the history of labor organization in the United States and talk a little bit about how it's actually regulated because everything that we do in our interactions or working in union environments is actually very strictly regulated. Look a little bit at what happened with the labor organization in the United States and how the history of organization for labor started, why it was started, and then a little bit of discussion about the difference between right-to-work and non-right-to-work states and how that may actually really impact how you do or do not experience unionization in healthcare, and then we'll take a look at some of the trends in healthcare labor organization, looking at various states, and I'll talk a little bit more specific about some personal experiences in New York, and then talk a little bit about some future trends and what's been seen in the statistics about what's happening among physician organization, residents, and faculty in attending. So history of collective bargaining. Unions are the right for collective bargaining in the United States was really established in 1935. Prior to that, there were strikes and there were basically all sorts of conflict that existed within labor. There had been attempts at bargaining, but it really was very disorganized, and I'll talk a little bit about what happened and why this led to the establishment of the labor unions by the National Labor Relations Act or the Wagner Act, which was passed actually in 1935. It's named after Senator Wagner, who was the person who sponsored it. That act actually established the whole concept of collective bargaining and how people were actually going to be able to, in an organized fashion between labor and management, create agreements that then would be able to allow for all of the needs of both management and labor. For wages, benefits, and working conditions. This is what is the majority and only things that really are covered by collective bargaining. It represents members in disputes with management, and the NLRA, the National Labor Relations Act, was established in response to the instability that was caused between labor and management conflict prior to 1935. The government had a very strong interest, along with the states, in stopping ongoing conflict, which actually had become quite bloody and was extremely economically disruptive. It needed to stabilize the labor markets because you would have mass shifts of labor as people were in mass laid off or in mass walked out on various jobs. And these pictures are from that period of time. And you can see there's, well, there's rifles, there's guns, there's conflict, there's people in fights. And it was in that period of time in 1935, those five years before, there had been 27,000 work stoppages, 90 deaths, and the loss of 172 million workdays. And remember, the country at that time was about a third the size that it is now from a population base. That was a level of instability that couldn't be tolerated. And there was a frank concern on the part of the government and a lot of people that there would be ongoing conflict leading to actually socialism, communism. Those were the things that were concerned and it was expressed interest that they needed to stabilize the labor markets. So the scholars have actually described the conflict which is embedded in our national labor relations. Since the conflict of interest is regarded as inherent to the employment relationship, the use of economic pressure is seen as having a legitimate and appropriate role. And this is the view that was taken by many of the scholars looking at what the workers had as their actual ability to express interest and to express their power. In a collective bargaining model, conflict is viewed as natural rather than a morbid characteristic and its expression through the strike is regarded as integral to the system that permits the parties to seek their self-interest. So you ended up creating a legal framework which was also organized that if the workers were to actually express their economic power, they could go out on strike, but in an organized fashion. And it also regulated that labor would not be able to, in a disorganized fashion, displace workers and that there was a process of order that would allow for a reasonable negotiation process. And the big thing here, and this is the source, is that this was attempting to take a physical conflict and turn it into a negotiation or a discussion form of conflict. So the risks of conflict actually flow from the legal structure and the protocols that we actually see. Sorry, it's like... So this is basically a historical situation of an adversarial framework in labor relations. The strict separation of parties into labor and management causes conflict in the way that we have labor defined and management defined in the United States. They are not viewed as working on the same side of the table but on opposite sides of the table. And that relates to that original history of conflict. The intricate and formal processes of collective bargaining create a highly formalized milieu in which parties interact. There is a very strict framework of how unions can be created. And then once a contract is being discussed, there's a lot of framework of how the discussion is to go forward. What can be discussed? What's the formats for discussion? When discussion fails, how it can then go to arbitration. And then when all of that fails, how either labor has the ability to lock out the workers or the workers have the ability to go on strike. And the restriction on cooperative dealing further inhibits communication. In the way this works, side deals and the ability to do side negotiations are not allowed. So this is actually a way to prevent fragmentation on either side. So if there's a labor discussion with an union versus a management structure, parts of the management cannot go and make a side deal with the union for what they want to do. So, for example, if Ford is having a discussion, the Lincoln factories can't go and have a separate deal where they say, well, we make more money per car so we're willing to settle, whereas Ford can't. And contrary side, you can't have part of the labor union saying, we're the steel workers and we actually want to make an arrangement whereas the other workers who are maybe, for example, an electrical don't want to do that. It all has to go all or none. And it's all or none on both sides. So conflict is a natural part of this. And if you look at the literature and you look at the posters and you look at the advertising, going back to the classic advertisement here on the left with United We Bargain, nice classic 1930s, 40s type of illustration to the 1960s with the raised fist to union strong SEIU healthcare, that is 1199 workers which are our healthcare workers in New York to the fight back against anti-union forces in public schools. All of this gives you an idea of this idea of conflict is built into the process whether we like it or not, unfortunately by the structure of this adversarial setup. This is an illustration from our own recent union efforts within our own institution where you had one hospital, one fight and you have the nurses and the residents actually working together. But this question is, is it really a fight? And this is something that I think we all have to take a step back and realize that although a lot of the language and a lot of the rhetoric associated is often very combative, the real thing is both sides generally really want to come to an agreement and they're just drawing strong opinions and strong requests and strong demands but it's really should not come down to a physical battle or a fight. So the fists are probably a little bit of an excessive expression of what is really going on in most collective bargaining. But what does the National Labor Relations Act say? Well, it says to bargain collectively is to meet at a reasonable time and confer in good faith with respect to wages, hours and other terms and conditions of employment. It does not respect other things besides wages, hours and terms and conditions of employment. So you can actually talk about in labor negotiation under the NLRA, pay over time, time off, retirement benefits, healthcare benefits, other types of benefits such as education or training or other things of that sort which you don't actually get to talk about is things that are outside of the employment. And so there are limitations that you cannot make demands as a union member or you can't make demands as management that like everyone has to live within the union town or everybody, those things can't be there. This is conditions of employment, not conditions of your living arrangements, not conditions of your life outside of the workplace. But this underlying part is important but such obligation does not compel either party to agree to a proposal or require the making of a concession. So although the NLRA creates a legal framework with which to confer in good faith and creates a framework about meeting at reasonable times, making sure that there's collective bargaining, it doesn't dictate that any settlement has to come out of this which is why we see lockouts and strikes. So you can get unionization and votes in organization that's in the NLRA, that's within the legal stream. It's a framework for fair negotiation so that there is reasonable negotiation. But once again, no compelment of agreement. But the big challenge in this whole thing is that it's based on an adversarial relationship which unfortunately often sets up a very difficult environment that sometimes starts out with negotiations. And we've all seen various unions and various management situations having very strong language said on both sides which sometimes I think is actually not necessarily constructive towards the creation of a good working relationship and the development of a contract that both can agree to. But this is unique to the structure of the NLRA. Most other unions in most other settings, for example, in Europe, it's not set up as an adversarial relationship. And in fact, many people are surprised to find out that in Germany, for example, Mercedes, BMW, those large car makers, the workers unions actually have members of the union on the board of directors of Mercedes because there's a recognition that actually there's a common interest that the workers need to be able to support the company because if the company is not successful, the industry is not gonna work and then the workers won't have a place to work and vice versa, the industry recognizes that if the workers are not actually well compensated and contented that they will not be able to maximize the ability to have high production and have good outcome for the company. So that there's a reasonable understanding that the company and the workers actually have a certain degree of common interest. And so when they meet and they negotiate, the negotiations are usually not as antagonistic. Of course, that doesn't mean that unions don't strike. You can go to Germany right now and I think the railroad has been striking 10 times where you can go to England on any given day and there's strikes and France, heaven knows, there seems to be another strike every week. But generally, it's not always, but generally the rhetoric and the heat and the discussions is not as adversarial. It's just, there hasn't been an agreement so we're gonna walk out. And then everybody goes and has wine and cheese under a tree until they come back. But what is this impact of unionization on the working relationships? Well, when employees are represented by a union, it's illegal for the employer to deal with the employees directly. The employer must bargain directly and only with the union. So this is something that takes away the individual negotiation, which creates an equal playing field for all of them, all of the workers, but it also means that the employer cannot directly deal individually with employees and have separate and different relationships and agreements. So once collective bargaining is represented by a union and has been designated or selected by its employees, it is illegal for the employer to bargain with individual employees, groups of employees or other employee representatives. This is all basically in the NLRA. I'm just reading you what's in the act. If there's a grievance or dispute that an employee would like to resolve with management, it is only allowed if the union is given the opportunity to be present at the meeting. So basically what happens is that the union actually then acts as the go-between for any employee and the management. And management, for anything that they have, which is a problem with employees, needs to also go through the union. So it does introduce protections, but it also introduces obstacles. And there's a lot of times when this seems to be a very inefficient system, but I think the inefficiency is built into it to create a certain degree of inertia so that there's not a lot of radical change. Because remember, in 1935, there was a lot of fear of radical change. So how does the place get unionized? How does the union vote occur? Well, the NLRB, which is the National Labor Relations Board, which is in Washington, it's part of our government, gets what's called the labor petition, which means that the workers in a location said, we think we might want to become a union. We might want to have collective bargaining with our employer. And then that's all handled according to the NLRB rules. It can be a national organization, like the AFL-CIO, or 1199, or the New York State Nurses Association, which is NISNA, or it can be a local group. You could just have a group of employees that work in a location without any national organization. They can also get together and say, we would like to collectively bargain. And they can submit a petition to the NLRB that there would be a vote for a union or not. The employer has to file a statement of position, which is basically, the employer has to say, yeah, you know what? I think it's fine. If the employees want to unionize, we're cool with that. That's good. Everything's good. You don't have to have a union vote. The union votes are only if the employer says, I'm not so good about this. I would actually like to hear if my employees, as the majority, would actually want to have this. And the NLRB can then also schedule a hearing to review the petition. So if there's a question about whether it actually was a real petition, were enough people on the petition, or anything else that might be with that, the NLRB schedules basically a NLRB court trial where they will review the application, review the petition, and then decide whether or not it's fully valid. And if it is, then NLRB will set a date for the secret ballot election to be done. The election is only for the workers at that point to decide whether they want to have the union or not. It's not a contract. There's nothing of that sort. The only thing that happens then is that the union is organized, basically that the workers are actually then created into a collective bargaining unit. After that collective bargaining unit is formed, that is when there may be the beginning of a contract process. So what happens after a unionization vote? Once again, coming from the NLRB laws. To be certified as the bargaining representative, an individual or labor organization must receive a majority of the votes cast. That means if there's 100 employees and 51 vote for and 49 vote against, the union has passed. It just has to be one vote more than the nos. Once an employee representative has been designated by the majority of the employees in an appropriate union, the act makes the exclusive bargaining agent for all employees in that unit. So what often happens, and you'll hear about there's a president of the local union, the president of that union is that designated individual who is now the person who will do all the face-to-face negotiation regarding labor issues with management. And management cannot talk to any of the other employees. They only can talk to that designee. So that's when you have all of these negotiations. And that becomes a face-to-face negotiation with that president or the leader of that union collective bargaining unit. So the basic components, there's three things as defined by the National Labor Relations Act. You have to meet at reasonable times. That means you can't say, oh, we're going to have negotiations start at 2 AM on the middle of a holiday. It has to be that everybody, both the management and the employees, can attend. So usually these things happen 9 to 5, Monday through Friday on business days. Have to confer in good faith. You cannot walk into these meetings and be flagrantly not willing to discuss. There has to be, you may have very strong opinions. You may have very, very divergent opinions. But it has to be in good faith that there's going to be an attempt to try to actually come to an agreement. And it should only be about wages, hours, and other terms of employment, not about other things. Now, the big thing, remember, is there's no requirement for the parties to reach an agreement at any particular time, make any concessions, or even come to an agreement. And that's why we see negotiations often failing, like we had the strike with GM and Ford and Solantis this summer. That was because they couldn't come to a full agreement. Eventually, it was like a partial strike. And so they kept on talking, kept on talking, and eventually an agreement was come to. But it's about basically wages, hours, and terms of employment at reasonable times and conferring in good faith. If those things aren't met, then one side or the other will be seen to be in basically noncompliance with the law. And that's when an arbiter from the NLRS can come in and force this to actually happen. So parties are required to bargain over the mandatory subjects of bargaining. They include pay, hours of employment, insurance, seniority procedures, and other conditions of employment. They're not required to bargain over non-mandatory subjects. So once again, going into that basic guide for the NLRA, management decisions such as subcontracting, relocation, other operational changes may not be mandatory subjects of bargaining, even though they affect employees' job security work conditions. So for example, if the employer decides they want to close a place of employment, that could be a factory saying, we're not making enough of this car. We're going to shut the factory. That's not something that's subject to negotiation. For us in health care, that would be if our hospital or your health care system decided that clinic is going to be moved from one town to another town because that's going to be better for us, because that's going to be better for our patients. But the employees are like, well, we have to now drive half an hour further. It's like that's not considered conditions of employment. That is, relocation of the business and mandated information about how the business is run, negotiation. Unions also cannot say whether or not stocks can be split or a company can go into negotiations to acquire another company. And none of that is going to be topics of negotiation. And that's written in the NLRB. It's not part of the negotiation. It's only about pay, hours of employment, insurance, seniority, other conditions of employment. So how does bargaining work? Hopefully, it's as civil as we see in the picture on the bottom. Each side has a representative on their bargaining committee. There's a professional negotiator usually for the employer or hospital. So you don't usually have management just go in it without having advice and support from legal counsel, as well as other people who have experience in doing professional negotiation. The union has a representative for the union. In a small organization, it may just be the president or the shop steward of the union who goes to negotiate. If it's a large thing like when they have GM with the AFL-CIO, they themselves have lawyers and professional negotiators who will also sit on the other side of the table. The employer, hospital, and the union make proposals for what they want. They then try to reach an agreement through discussion, trade-offs, and compromises. So everybody goes into these negotiations with some things that are points that they will not give up on, and then other things are, so to speak, the wish list. And those are things that are negotiable, that if I can get it, that's wonderful. If I can't, I'm willing to give that up, and then allow the other side to gain a point as well. But neither side is required to agree to anything that it doesn't want to accept. And if you remember that strike and the negotiations with the auto manufacturers, there was a request for something like a 40% salary increase, which was an ask and a reach, which I don't think the union ever thought that they would get either, and I think they would have probably passed out if they had gotten that on the first negotiation. But they ended up getting something in the 20% range. And the companies came in saying 10%. And then it becomes like a horse trade. It's like you go to an antiques fair, and you see something you like, and you offer a price, and the person selling it asks the price, and you eventually negotiate, hopefully, a deal that works. But just as you are when you're at the flea market, you can walk away from the deal. So there's no guarantee of a positive change or a negative change. There's no guarantee of any change when you go into bargaining. They often, the unions, will promise a great deal, but they can't guarantee it to the members. And the same thing with management. Management will often say, oh, we're going to hold the line, and we're not going to let anything happen. But often, because of the realities of trying to get their company or their operation working again, they often then make compromises as well. Any changes to pay benefits or working conditions only happen if the employer and hospital agrees with them and if the union agrees to them. There's a process, but not an outcome. Union representation does not imply the right to a better deal. And this is basically what's written in a federal court case. The right to union representation under the NLRA does not imply the rights to a better deal. The proper role of the NLRB is to watch over the process, not guarantee the results of collective bargaining. This has been basically litigated multiple times where people are like, well, our union didn't get us a better deal, so the union failed. Or we actually are suing the employer because they didn't give us what we were looking for. There's no obligation for either side to give in and make a better deal. So what happens when parties can't reach an agreement? And this is what gets everybody all excited. Bargaining process can continue and continue and continue. And I know that we have at our hospital had negotiations that have lasted two years beyond the expiration of the contract. The past contract continues until we get to a new agreement. And that's what's called lapsing with no agreement. But that doesn't necessarily mean a strike. It just means we keep on negotiating. But while that's happening, we can't change anything on pay, benefits, or working conditions. And the people who work in the union can't expect to change what they're doing and get more vacation or take more time off or do anything either. The contract is frozen where it was at the time of the lapse. It doesn't move forward for either party. Now, the law does provide each side with economic weapons. They have, in this adversarial force, something that each side can use in bargaining, including the union can call a strike and try to force the employer to agree, creating economic pain by loss of money in the process. The employer can lock out the employees to try to force the union to agree, making the employees feel economic pain. But in both of these, both sides are feeling pain. If you have a strike, the employees are not working. They're not making money. And the boss and the company are not making money. On the other side, when you lock people out, you can try to force the union to agree. Yes, the workers aren't getting paid. But guess what? The company isn't making money. And part of the NLRB says that the employer, when they do a lockout, cannot bring in replacement workers. However, if a strike is called, then the employer can bring in replacement workers. So you cannot bring in replacement workers if you choose to lock employees out, because that would be unfair advantage. Implement a final offer. The employer can, if you get an impasse, whether the final offer makes positive or negative changes, can implement its final offer if they've gotten to a good faith impasse. This is something where the NLRB will look at it. The mediators from the NLRB will say, everybody has gone as far as they can. This is the best deal they can possibly make. The employer can then implement that offer. So you don't see this often, but it does occasionally happen. So then what happens? You get strikes or lockouts. On the left side, you've got the employers who have locked people out. On the right side, you get strikes. And that's where you once again get that image of conflict from the old cartoons of the employer and the worker fighting each other to the death. It's a little bit different in some hospitals and public institutions. The public institutions don't work under the NLRB. The NLRA only works for nonprofit, private employers, or for-profit hospitals. It doesn't apply for state hospitals, VA hospitals, federal hospitals, places that are under government contract. So the public institutions, city, state, federal institutions aren't covered. Contract negotiations with public institutions are very different. Usually, the employees cannot strike, which is a very strong limitation on what their ability to negotiate is. And there's a binding arbitration process to settle the contract if the parties can't reach an agreement. In the NLRA, they actually have an observer who makes sure that there's a good faith attempt at negotiation. If it fails, there could be the implication of the best offer. But in a public institution, if there's no successful negotiation, there can be an independent binding arbitrator who then comes and settles the contract for the parties. As I said, no binding arbitration under the NLRA. So collective bargaining is a legal process with formal rules and some limitations. It's designed and created for a very different time. So it was created in the 1930s. Which was a very different time than now. And in some ways, we are still dealing with some of the anachronisms. Because despite the fact that this is essentially a 90-year-old law at this point, it really hasn't been much amended. So there's no disputing the fact that maybe there should be some revisiting this. Because there could be some things that could actually maybe adapt to the new labor situation. Where in 1935, it was mostly about people doing manual labor, working in factories. And now, a lot of the people who are unionized are doing cognitive and other work, which is potentially very different. It's a process that can encourage confrontation instead of cooperation. It can close the door on communication between management and employees. Because remember, only the chief negotiators can talk. You can't have backdoor deals. So it really limits sometimes the paths of communication. It has worked to create improved worker conditions. The 40-hour work week, improved wages, better benefits, worker protections, retirement plans, these are all things that came about because of unionization. And union membership did peak in the 1950s and 60s, but is very, very small now. It was 35% of the workforce in 1954. It's about 10% now. So what is the state of unions in the United States? In health care, 13.2% of health care workers are unionized. That made me realize I'm in a kind of a unique position. That's like about 1 in 10. Compared to non-unionized health care workers, though, unionized workers have a higher weekly earning, by about $120. They have a higher likelihood of having a pension or other retirement benefit, by about 15%. Older health care workers were significantly more likely to be unionized than younger health care workers, which I thought was very interesting. Only 8% or so of the workers who were 15 to 29 years old in health care were unionized, whereas when you get to people who are over 45, it's around 15%. Nurses had the highest level of unionization, and physicians, dentists, and technicians, and support staff had the lowest rate, about half of what the nurses had. It also was interesting to me that people of color, Asian, Black, Hispanic health care workers, were also more likely to be unionized. And there was also an interesting thing that in, I don't have the data for 23, but in 2022, the first half of 22, the NLRB reported a 57% increase in union election petitions. So there's a lot more interest in unionization in a lot of health care settings. Now, right to work, I'll talk briefly about that. A right to work state is a state where you can be in a union setting, but you don't have to pay the union dues. In most normal unions or unionized settings, if you are working at that institution, you are mandatorily a part of the union, and you have to pay the dues. In a right to work state, you can work at that place and elect not to be part of the union. Now, this is a very strong way to actually decrease the effect of unionization, because the unions make a lot of their money, most of their money, if not all, from the union dues. And so if you have most of the workers not choosing to be part of the union, the union's effectiveness is markedly decreased, because they don't have a strike fund. They don't have the money to actually hire the lawyers. Then you can understand all the things that that would limit. So if you look at the United States pre-2010, all of the red states were right to work. The blue states are the ones that are currently non-right to work, meaning straightforward NLRB unionization states. Post-2010, the right to work was extended in several states, but there is one exception in that Michigan became the first and only state that was right to work that reversed the right to work law in 2024. I don't know if that states anything, but it just shows that there has been a large flux of motions to create right to work in many states. But the Northeast, the West, and some other states in the middle of the country are the ones that are still mostly, quote, unquote, union friendly. Now, once again, for the reasons I talked about, right to work can severely limit unionization. It's also not equally spread. So the percentage of people who are unionized, the darker, the higher the unionization. Once again, I came to realize, yes, I'm in a very unique place. Hawaii has the highest percentage of unionization, around 25%, but New York is around 24%. So it's right behind. Health care unionization mirrors this. And so if you see, in New York, we have one of the highest rates of unionization along with Washington, California, surprisingly Alaska, Hawaii, and of course, Minnesota has a lot of unionization in health care as well. What does unionization have to do with earning? Well, you could see most of the metrics that you look at in most groups, you make more money in a population where they are unionized rather than non-unionized. It also has a large association between pay, work hours, and non-cash benefits. Overall, there's a significant increase in weekly earnings, insurance contributions by the employer, mean hours of work per week, meaning less hours of work, pension and other benefits, and health insurance plan. But it's not for everything. So physicians and dentists really only gain a benefit in pension and health insurance, whereas advanced practitioners get pretty much everything except weekly earnings. For nurses, it's earnings and benefits. For therapists, it's really benefits. And for technicians and support staff, it's most everything. Not necessarily significant for the health insurance plans. Now, physician training. This is a new thing in some ways, in that residency programs are becoming more unionized. And if you look back historically, there was a couple of places that unionized up until 2022. Then in 2022, and I think maybe this was in large response to the stress that happened with COVID and other changes, there was a marked increase in interest in unionization. And you could see that there were four union votes, all successful. And then in 2023, there were seven union votes, all successful. And surprisingly, yeah, my campus was in there too. So we also got unionized. So it became something where we became much more aware of what was going on with unionization and some of the impacts. So what are the future trends? Well, if the recent past is pro-unionization, if the recent past is prologue, we'll probably see more resident organization in states where it's possible. The potential for faculty and attending organization where physicians are employed. Especially, I think this may become something more common in the future, as many residents who then become faculty members who were in unions and may have had a positive experience may also view becoming unionized. Now, why would this happen? In the past, unionization among physicians was highly unlikely because most physicians were their own private businesses. They were the bosses. They weren't the workers. But it's become that with the expansion of managed care and the expansion of health care organizations, most physicians now are actually employees of health care systems. So they may be moving more to the labor side and less to the management side. Depends on your setting. If you're a private practitioner, you're not unionizing. If you work for a large health care organization where you are an employee who gets weekly salary and benefits, you might be more favorably inclined, especially if you've been a union member as a resident. The right-to-work states will likely have the slowest union accretion that would go probably along with what we've seen for the rates. And what does it mean for health care? Well, costs will go up for the health systems that are unionized. It's generally about 20, 30%, they say. I don't have the numbers to actually establish all of that, but it does, as you see, you know, if you're paying the workers more and they're working a little less time, it doesn't take a lot of science to figure out it's probably gonna increase costs. Benefits for the employees can be seen. They get better benefits programs, more vacation, better time off, better retirement benefits. Strikes and lockouts are very difficult and costly for both sides. We went through a, one year ago in January, we and Mount Sinai were struck by the nurses unit. It's a very painful process to go through. I've lived through several strikes. The hospital health care system can work, but it's very costly to bring in replacement staff. It is also not very conducive to quality care because it's disruptive. You have people who are unfamiliar and a lot of the physicians and other workers are doing tasks that were being done by the people who are out on strike. So it can be quite disruptive. So in conclusion, it's important to understand the process and the effects of unions. There's benefits and challenges, both for the employees and the employers. Benefits for the employers, you can say, well, I see a lot of things and money and so forth. For the employers, you're not dealing with individual employees who are actually asking for benefits and things. What you're doing is you've got a contract and you go with it. As one of the people that I know who's worked with residents and unions, it's like, you don't have to negotiate with the resident about, are you gonna get an extra couple of weeks off? It's like, is it in the contract? You get it. If it's not in the contract, talk to your union representative because it's not there, it doesn't happen. So it makes sometimes things a little bit more black and white and simpler, but on the contrary side, it makes it black and white and very hard to be flexible. Challenges exist in the adversarial nature of how the NLRA rules. It's really very important to try to have as friendly a negotiation as possible because that way you can avoid lockouts and you can avoid strikes and you can avoid all of the really unhealthy kinds of things that then often push people into corners where they don't necessarily even want to do the things they do, but they're doing it because they're in this adversarial state. Public sector has different rules. So if you work in one of those settings, remember union strikes are illegal. Remember the Patco strike. Remember how Ronald Reagan fired all of those workers because they were federal workers. They were not allowed to strike. In private settings, that does not happen. You cannot do that. You can't fire people. You can lock them out, but then you're basically closing your hospital. You can't bring in the substitute staff. If there's a strike, you can bring in the substitute staff to keep the operation going, but you have to keep on negotiating and you cannot permanently replace the workers. Votes for unionization, negotiations, strikes, lockouts, they all have rules that are regulated by federal law and the NLRB. So it's not like this is an arbitrary thing that can come out on a Friday night and all of a sudden on Monday, you have a union. There's a long process and it takes months to go through this process. It probably takes up to six months or so for a petition to go into the NLRB, all of the appeals to be made, and then for a date to be set to actually have a unionization vote. Unionization in healthcare varies a lot by locations. There's more organizations in states without right to work. So if you're in a right to work setting, you probably are not highly likely of having unions. If you are in the other states that are not, as you can see from the graphs that I showed, you may actually have about a one in four chance of having a union in your location. There's more urbanization, more urban unions than there are in rural settings, more in the West Coast and Northeast. And now I can actually open this up to questions and I think we have about 15 minutes for that. And I'll escape so that people can actually show themselves, I guess. So Dr. Hamilton, do we have any questions? Hi, I'm looking in the chat, but I think Brian and Sammy may have that. I mean, if people want, I could talk a little bit about some of the experiences of going to the NLRB. I'm not going through a strike, but. So Dr. Bartles, while we're kind of looking for people to ask questions or type in questions, most of us on this call are leaders or will be leaders or how, I mean, with this, how do you have to change your leader? I mean, I think about the leadership classes I've sat through, right, about communication. How did you change or how do you have to change to, I guess the word is accommodate the union? That's actually a very interesting question. I actually have never worked in a non-union environment. So I'm not sure exactly how I would interact in that environment that would be different than what I do in a union environment. But I mean, respectful negotiation, respectful work with your employees, I think is a good rule for anyone. You're kind of mandated in a union situation to do that because grievances could easily be filed. And so all the communication has to be held at a respectful nature. One of the things that being a leader in a union environment is to realize that not all of the grievances or complaints that may be filed are personally directed. A lot of this is done through the union itself and through their interpretation of what the contract says. So they may not be saying, oh, Dr. Hamilton, you're a terrible person because you're not giving me a vacation, but they may actually be filing a grievance saying, my interpretation of the contract is I'm supposed to get an extra day for eclipse day. And that it's not a personal thing against you. It's their interpretation of the contract. Sit down, you look at it. If it's in the contract, they get eclipse day. If it's not in the contract, they don't. But you do need to understand that. Now, it also means that you have to be much more careful and well-documented when you have an employee, for example, for termination. And for an employee, that's protection that, just because the boss doesn't like you, they can't get rid of you. But on our side, as a leader, it means that if you are going to have an employee that will be terminated, you have to have cause. You have to document well that they've been consistently late, they've been disrespectful to the patients, they haven't been documenting appropriately. They have been, you have to have the clear things that are not keeping up to the standards. And I've had situations where employees have grieved their dismissal or their punishment or whatever it may be. And the union representative sat down and said, well, you're just not doing a good job. So you should get what you're getting. And I was like, whoa, you're really saying that? And they're like, yeah. They're not doing what they're doing. I sat in one situation where somebody was complaining about having to work evenings and weekends. And the leader of the 1199 union looked and said, you're in healthcare. This place runs 24 hours, seven days a week and holidays. You get to do your share. I looked, you're not doing more than your share. You're doing what everybody else is doing. So you need to just go back and do your job or find another job. But this is not the employer being unfair. So sometimes actually the unions can be helpful. On other times you can find them and think that they're infuriatingly non-helpful. Some of the limitations that union employees may find is often the seniority requirements. Seniority is built in. And often it means that if there's a position that opens up that's more senior, it's the person that has been on the job the longest gets first option on the job. Whereas you as the employer were like, oh, we have that brand new employee who's like fifth in line who would be perfect for that position. They only get that if the four people ahead of them say, no, I don't wanna take that job. So you can't, you as the employer can't say, I want that employee to go into this position that's opened up. It has to be opened up fairly. And usually job openings have to be, for example, with 1199, they're opened up in the hospital. So that if let's say I have an 1199 clerk position that opens up at our outpatient clinic, it has to be opened up first internally for a week so that employees at other clinics can say, I'm tired of working in surgery. I heard rehab is a really nice place to go. I wanna apply for that job so that they can transfer internally. Then it's opened up to all 1199 employees in the New York area so that an employee over at Harlem Hospital or over at another hospital says, I moved to the Bronx, I really wanna be in the Bronx. I'm gonna see if I can apply for that job. And if there's no takers on that level, then we can open it up to the general community. So that doesn't mean it sounds like we'll never get outside employees, but that's not true. But there's a couple of weeks where it has to go through internal, union itself, and then it's opened up to the world. And that gives protection to the union workers. So that, you know, it's very nice for the workers who are in the union. It could sometimes be a little inconvenient for the employer, because sometimes it takes you a couple of extra weeks or more to hire employees. But that's just part of the nature of how things go. So yeah, that's another management thing. You have to plan more. Okay, I have a couple of questions in the chat. Can unions help out in hospitals that are bought out by venture capitalists? All right, that's an interesting thing. Yes. If a hospital is bought out by a venture capitalist or a practice is bought out by a venture capitalist, I understand now that apparently, like half of the ER docs working in the country work for these venture capital firms. I was totally blown away when I heard that. Those are by definition, private employers. And they can be unionized. And if there's a union that's brought in, the union cannot make the venture capitalists not sell the hospital, not try to take profit out of the hospital. Remember, unions cannot say anything about how management runs the business. But if there's concerns that the venture capital or the new owner is making people work different shifts, is cutting pay arbitrarily, is not honoring prior retirement contracts, things of that sort, then a union could be very helpful because under that, those are the terms of your employment and those could be protected. So yeah, I mean, venture capitalists probably are not all that eager to buy out a unionized institution because they cannot make the big changes that might actually make the profits start to flow. So that does protect employees. But on the other hand, if your institution needs that infusion of cash and you can't get that capital, that might make it hard to make your institution work as well. So it works on both sides, but yes, unions could quote unquote help out if you're thinking about trying to protect the worker rights or to protect the employee rights in a setting like that. But they cannot help out if you're thinking about not breaking up the hospital or not shutting the inpatient beds and turning in an outpatient surgery center. That is something that the venture capitalists could do no matter if there's a union or not because that's running the business and that's not part of the collective bargaining agreement. Right, another question here and bear with me. Positions are in a lower position to negotiate insurance contracts rather than employment. Will unionization help with that? And in addition, you stated that unionization will not work for government positions or public institutions. So it does not seem that unionization will help us with contract negotiations. Any thoughts on that? All right, it's two questions. Well, the first one is if a physician and I'm presuming here you're not talking about residents but I think they're talking about attending level physicians are trying to get insurance contracts. Now the insurance contract can, is it Richard Ramos? Can you say, are you talking about your health insurance and your benefits? Or are you talking about the insurance with Health First and United and Aetna when you're talking insurance contracts? Private practice. Private practice, negotiating insurance contracts with insurance companies. Once again, that's not covered by NLRB because the National Related Relations Board covers your employees. So if you're getting your insurance, whether I can get a better health insurance plan for my family and myself, there's no guarantee, but a collective bargaining agreement may allow a group of physicians to get together and negotiate to get a better insurance for themselves through their employer. Let's say you work for a healthcare system, John Jones healthcare system. I don't hope there's not a John Jones system out there just making it up. But if you're working for X healthcare system and you're an employed physician and your benefits aren't good, that will help you to get a better insurance plan for you. If however, X healthcare system has miserable contracts to get payment from various insurers or you're a private practitioner trying to get payments from an insurer, that's not part of the National Labor Relations Board because that's the running of the business and that's something that management has to do. And the union cannot argue with that. And then the other question was about, it won't work. Unionization does work. And there are many, in fact, I think higher rates of public employees than private employees are currently unionized. The thing about it is that if you are in a union that is federal state or city, then you cannot go on strike. So the ability to negotiate and to apply leverage is a lot less and the other thing about it is that if the agreement doesn't come, now this is potentially dangerous for both the government entity and the employee, it goes to arbitration and the arbitrator then puts a contract in place. And I've seen times when the city or the state was holding out, they're not gonna do this, not gonna do that and they reach an impasse. And then what happens is the arbitrator comes in and says, you know what, the employees were right and what the government didn't want gets placed into place. I've seen it the opposite way too. And you cannot appeal it. It's when the arbitrator puts it in, it's done, it's finished. So there are less powers for negotiation in a union situation there, but it doesn't mean the unions aren't powerful. Everybody's seen teachers unions. They can actually do a very good job on getting great contracts. They have excellent healthcare benefits and retirement benefits. Salaries are generally not as good. So it does not seem that unionization will help us in contract. So if you're working in a VA or a city or a federal hospital, they will help, but you cannot pull the ultimate weapon of strike. You don't have the ability to strike the employer. So it has to be done through hard negotiation. And if that fails, you get arbitration, but it may actually still give you a better deal than if you're working one-on-one. I thought we needed to unionize to get better contracts, but that's not covered. Yeah, it's to get better contracts for your employment, your benefits, your salary, but it has nothing to do with the contracts that you have with outside entities for paying you for how much your patient's visits are or whether or not you're gonna have to negotiate for every MRI. That will not come from a unionization. Interesting question though, I have to be careful about when you say contracts, what we mean. There you go. Well, I see no more questions. I think that was great. I learned a lot and I appreciate you and the Academy appreciates you. And we thank everyone for their attendance this evening and wish everyone a great rest of the week. Thank you, Dr. Bartholz, that was enlightening. Well, thank you everyone for attending. And yeah, let me put it this way. If you don't have unions and unions come, it's not the end of the world. You can actually negotiate with it. You can work with it. We've had residents prior that were unionized because half of our residents came from a unionized setting, didn't treat them any differently. It doesn't really change any of those relationships. It's really only about their pay, their benefits there. So the residents may gain, they may get maternity benefits. There may be things like that, but it's not going to change the earth under your feet. But if you have a lot of other employees, it just makes you have to be a lot more meticulous about documenting how you're going through things. All right, thank you everybody. Thank you.

unionization in healthcare

physicians

residents

faculty

National Labor Relations Board

collective bargaining

labor organization history

NLRA regulations

worker conditions

healthcare labor organization