Fair Contract

Physician Unions Shouldn’t Be the Only Answer


Marshall Strome, MD MS

Publish date

Fair Contract: Physician Unions Shouldn’t Be the Only Answer

After learning that the house staff at Montefiore Hospital in New York voted to unionize, New York State Senator Gustavo Rivera stated: “I look forward to supporting them as they bargain for the fair contract they deserve.” 

Are unions the only option for physicians in training? Will a “fair contract” for house staff require sacrificing the interests of patients?

Reportedly, the roots of the Montefiore unionization began with Covid. The pandemic brought overwhelming numbers of patients requiring care: scarce resources, long hours, and stifling stress.

My Residency Training

In 1964, I chose Philadelphia General Hospital for an internship knowing that the 36 hours on 12 off for a year would be challenging. I prioritized caring for an impoverished population knowing there would be associated periods of exhaustion and very low wages. I spent a year on the University of Pennsylvania service, benefitting from superb teachers, constant encouragement, and the equipment to give a level of care I could be proud of. 

I chose this profession in dedication to selflessness, sacrifice, beneficence, and justice. To this day I believe it was all worth it. I never felt I needed a union to achieve these aims. 

At Montefiore and many other institutions, unprecedented Covid challenges impacted resident education. Exhausted the senior staff had little or no emotional or physical reserve to provide the guidance and support residents needed to thrive. The house staff faced shortages of essential personal protective equipment like face masks, gowns, and gloves. A lack of respirators and an insufficient number of ICU beds both contributed to needless patient suffering. As the work hours and deaths increased, so did the inadequacies so many house staff felt. Their lives were endangered, and many contracted the virus. They clearly were entitled to question their choice of profession and its poorly functioning support systems. 

Upon reflection, my experiences were dramatically different from Montefiore residents. Should I accuse the unionized house staff of being less dedicated and abdicating long-held ethical principles of caring for patients? I think not. I am concerned that increasing numbers of practicing physicians of all generations feel helpless and isolated. 

Changing Times

Times have changed since I became a physician. Today, over 70% of physicians are employed by large institutions, whereas in the past, most of us were truly independent practitioners. As hospital corporations and Private Equity owned practices grow, some physicians perceive profits prioritized over the well-being of patients and healthcare workers.

As a fellow of the American College of Surgeons, I pledged “to place the welfare and the rights of my patient above all else.” Can I honor this promise as a union member? Unions pose unique risks to patient care. I strongly believe there must be other options, besides unions, for professional and patient advocacy.

As physicians, we usually take pride in our autonomy, especially to advocate for what we believe is best for our patients. Unions require group unity, even when members disagree. Unionized physicians risk their ability to ensure patients get the needed care when doing so may violate a union contract. 

We must stress the following to our young colleagues: unions tend to stifle employee initiative, prioritize seniority over excellence, and favor group dynamics over individual considerations. 


From my perspective as a senior physician, our house staff is the future of this noble profession. I believe our profession is unique: not limited to a job but a calling. If we are to prevent a trend toward more house staff choosing union membership, we must engage them, understand their concerns, and explore alternative paths.

It is incumbent upon those with the skills to partner and negotiate with hospital leadership, local and national governments, and industry to effect positive change. We must work together to mitigate deficiencies, rather than remain bogged down in union negotiations. In my experience dealing with divisive concerns, proactive physician advocacy leads to satisfactory resolutions more often than not. 

Professional Reset

Our profession needs to reset to encourage young physicians to learn, acknowledging that they are our future and we are there to help them. Our medical leaders must stress what our lineage has been and should be: in service to our fellow human beings. Through the ages, physicians have known what is most important – giving the best of what they are in the service of the health of humanity.We are in a unique position where our fellow humans place all their trust in us. 

Our “fair contract” should be with patients.

Marshall Strome, MD, MS is a Professor of Bioethics and Humanism at the University of Arizona College of Medicine-Phoenix, an Adjunct Professor of Otolaryngology at Vanderbilt University and Professor and Chairman Emeritus at Cleveland Clinic Head and Neck Institute.

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