By Mary Meyer, MD, MPH

Among my possessions is a frayed newspaper clipping of the first time my grandfather was arrested for engaging in union activity. Edward Houchins joined General Electric (GE) as a factory worker in 1924. During the Depression, he couldn't afford just one job, so he worked weekends at the corner store; during World War II, his wages were frozen. But after the 1946 GE strike, his salary increased by 18 cents an hour. He eventually earned enough to send his youngest daughter to nursing school and she, in turn, sent her daughter to medical school.

Today, as a seasoned emergency medicine physician, I'd estimate that I've participated in at least 30 strikes -- but I'm on the other side. Historically, physicians do not strike, so when there's a work stoppage we fill in the gaps. I've started IVs and drawn labs, pushed gurneys to radiology, doubled as a physician's assistant, and even mopped floors. Once, I helped repair a broken sink. Sometimes it's the pharmacists striking, and sometimes it's the therapists. Or housekeeping or the engineers. What I dread most are the nurses' strikes, which are terrifying -- working a shift without enough nurses is like trying to be a doctor without my right hand (and I'm right-handed).

As you might imagine, there's no shortage of doctors grumbling when staff are striking, despite the pep talks from management and the free lunches. So lately, I've found myself wondering: are all these strikes really worth it?

The answer -- like so much in medicine -- is complicated.

Do No Harm

Throughout history, workers have organized when the perceived inequity between management and frontline employees reached a tipping point. In the U.S., unions arose during the Gilded Age as a backlash to poor pay and dangerous working conditions. They're credited with establishing the 8-hour workday, the federal minimum wage, and modern safety standards.

In healthcare, however, unionization has long been met with skepticism. At issue is whether healthcare strikes are unethical, given they could potentially imperil lives (they were once compared to airline pilots abandoning their passengersopens in a new tab or window mid-flight). It wasn't until 1974 that the National Labor Relations Act (NLRA) granted healthcare workers the right to unionize.

But the data on whether healthcare strikes actually cause patient harm is mixed. On the one hand, a meta-analysis of more than 700,000 patients found that strike action had no impact on patient mortality. On the other hand, strikes are certainly capable of causing broad health system dysfunction -- they are, after all, designed to disrupt care delivery. I've had patients who waited until after a strike ended to seek care for their chest pain or their stroke symptoms. I once treated an elderly woman whose surgery was delayed by a strike: she wept as she described her unbearable pain (I sent her home anyway: there were no openings in the OR). Inevitably, when a portion of staff walks off the job, something's got to give.

Corporate Medicine

But there's a pitfall to this debate about ethics: it generally fails to account for the conditions in which healthcare strikes now occur. Until the 1980s, 76% of doctors owned their practices. Then private corporations began acquiring healthcare assets, including physician practices, hospitals, nursing homes, and pharmacies. By 2023, 77% of all U.S. physicians were employed by a hospital, corporation, or private equity firm.

These corporations are accountable to their shareholders, so the interests of patients and the healthcare workforce fall second to their primary motive: profit. Profit has always existed in medicine -- doctors and staff rarely work for free. In today's medical ecosystem, however, decision-making and accountability have largely shifted to administrators far from the bedside. If you don't believe me, just try to figure out who denied your prior authorization: you can spend hours on the phone and never actually get an answer or reach another human being.

The result is widening pay disparities that some have called the Gilded Age of medicine. The highest-paid nonprofit hospital CEOs earn around $14 million annually, and the top-earning health insurance CEO made $26 million in 2024. The median annual income for a registered nurse is $93,000. For orderlies, it's $39,000. For the clinician workforce, corporate medicine has translated into worsening burnout, job instability, and workplace violence. And, for the people it's supposed to serve, healthcare has become increasingly unaffordable, inaccessible, and error-prone.

I find myself wondering whether healthcare unions -- with their emphasis on economic equality, patient care, and clinician autonomy -- are one of the few remaining counterbalances to corporate medicine.

The Cost of Not Organizing

When I was 14, my father watched in astonishment as my mother joined her nurse union's picket line. As a gastroenterologist, striking was inconceivable to him. For one, he was ineligible to unionize, as he belonged to a physician-owned practice. It also just wasn't done -- it violated an unspoken code of conduct amongst physicians.

I would be remiss not to point out that there is a cost to not organizing. By the time the NLRA was amended in 1974, healthcare's lowest-paid workers -- orderlies, janitors, nurses' assistants -- were regularly paid below minimum wage, lacked basic protections such as water breaks and air conditioning, and could be fired at will. (For context, unionized GE workers had by then achieved cost-of-living adjustments, paid time off, and health insurance.)

Today, unionized healthcare workers have significantly higher wages and better benefits (including health insurance) than their non-unionized counterparts. They have less gender and racial wage inequality. There's also an association between unions and better patient care in some settings, in part through unions' impact on staffing ratios, turnover, and workplace conditions.

They're far from perfect, of course. Unions sometimes protect under-performers and underpay over-performers. They can also be as bureaucratic and obstreperous as the corporations that now own much of medicine.

What is certain is that healthcare unionization is growing. And perhaps most tellingly, membership in physicians' unions has surged in the last few years. Increasingly, unionization is perceived by physicians less as a lapse in professionalism and more as a vehicle to address the worst aspects of modern medicine.

A Work in Progress

There was a time when I resented healthcare strikes. Over the years, I've come to a more nuanced opinion -- a realization that these strikes are best understood as a window into the broader underlying trends in healthcare and its many stakeholders. Increasingly, I also suspect the short-term inconvenience of healthcare strikes is probably outweighed by their long-term benefits for patients.

Do I enjoy pushing gurneys during a strike? No. Do I still fear a shift without adequate nursing? Absolutely. Will I ever join a union? Probably not -- I am fortunate to belong to one of the few remaining physician-owned practices. Ultimately, as a physician, the most important part of my job is to relentlessly advocate for the health of my patients. It just may be that pushing gurneys during a strike is now part of that equation.

This perspective is the author's alone and does not necessarily reflect that of any institutions or companies with which she is affiliated.