Newsletters

POSTED: June 19th, 2026
POSTED IN: 2026 EM Pulse Q2, EM Pulse - The Official Newsletter of MOCEP, forum, Forum Topic,

Written by: Joseph Schuster IV, D.O.

For most of the 20th century, physicians practiced as independent professionals — owners of their time, their practices, and their clinical decisions. That era is largely over. Beginning in the early 2000s and accelerating sharply through the 2010s, private equity firms and large hospital systems began acquiring physician practices at scale. The pitch was appealing — competitive salaries, liability relief, and freedom from the administrative burden of running a business. What many physicians received in return was something far less appealing — loss of autonomy, and a seat at a table where they were no longer invited to speak.

Emergency physicians know this dynamic intimately. Decisions about department operations, staffing ratios, and patient flow are increasingly made not by clinicians, but by administrators with MBAs and productivity spreadsheets. Cutting physician coverage during surge periods or reducing housekeeping staff to trim overhead are not abstract policy debates — they are decisions that directly affect whether your patient in bay 7 gets timely care. Healthcare is undeniably a business, but when business logic consistently overrides clinical judgment, patients pay the price.

So how do physicians reclaim their voice? One answer that is gaining traction — and controversy — is unionization.

A Movement That’s Already Underway
Physician unionization is no longer theoretical. A December 2024 JAMA study examining trends in attending physician unionization found that union petitions filed with the NLRB increased significantly from 2023 through mid-2024 compared with the prior two decades, with organizing efforts driven primarily by concerns about working conditions, clinical autonomy, and voice in management decisions that affect patient care.¹ To put the pace in perspective: the union drives from 2023 to 2024 alone represented nearly as many new physicians as had unionized over the previous 22 years combined.² The movement is accelerating.

The Case For: Patient Care and Physician Autonomy
Proponents of physician unions point first to patient outcomes. When physicians have meaningful input into hospital policy — staffing levels, surgical scheduling, throughput protocols — care improves. For emergency physicians specifically, the downstream effects of administrative decisions made without clinical input are immediate and visible: boarding times climb, nurses get pulled, and patients deteriorate in hallways. A union contract that gives EP groups formal standing in operational decisions isn’t a labor perk — it’s a patient safety mechanism.

The autonomy argument is equally compelling. Physician burnout is at crisis levels, and research by Shanafelt and colleagues has consistently identified loss of autonomy and administrative burden as among the most prominent drivers — factors that collective bargaining is uniquely positioned to address.⁴ Documentation mandates designed for billing optimization, RVU-based compensation that incentivizes volume over judgment, and noncompete clauses that trap physicians in unfavorable contracts — these are not clinical problems, they are contractual ones. Unions have leverage that individual physicians do not. Collective bargaining can challenge or eliminate policies that administrative medicine has normalized but that most EPs would describe as plainly demoralizing.

The Case Against: Real Concerns Worth Taking Seriously
The objections to physician unionization deserve honest engagement, not dismissal.

The most visceral concern is the strike. In November 2025, physicians were among the 600 clinicians who participated in a one-day work stoppage at Allina Health in Minnesota — the first physician strike in that state’s history.² For emergency physicians, the ethics of a work stoppage are not abstract. We do not treat elective cases. Our patients did not choose their timing, and many have no alternative. Any honest discussion of physician unionization in emergency medicine must grapple with this directly. Most physician union contracts include no-strike clauses or essential services provisions, but those protections are negotiated, not guaranteed.

A second concern is the adversarial dynamic. Collective bargaining works by formalizing conflict — it creates a structured opposition between labor and management. Physicians who value collaborative relationships with their hospital administration may find that dynamic corrosive, even when their union wins. There is a real risk that gains at the bargaining table come at the cost of the informal influence and goodwill that many physician leaders have spent years cultivating.

Finally, there is the legal and structural complexity. Under the National Labor Relations Act, the right to unionize applies to employees, not independent contractors — a distinction that excludes a significant portion of private practice physicians. Even among employed physicians, forming a recognized bargaining unit requires navigating NLRB petition processes, defining an appropriate bargaining unit, and achieving majority support. These are not insurmountable barriers, but they are real ones.

The Bottom Line
Physician unionization is not a silver bullet, and it is not the right fit for every practice environment. But for emergency physicians working in health systems where clinical voices have been systematically marginalized, it represents a legitimate and increasingly utilized mechanism for reclaiming influence. The question worth asking is not whether unions are ideologically comfortable — it’s whether the status quo is working. For many EPs, the honest answer is no.

References:

1. Rooke-Ley H, Richman B, Bowling DS, Schulman K, et al. Unionization efforts by physicians between 2000 and 2024. JAMA. 2024;333(4):347–348. doi:10.1001/jama.2024.23721
2. Cimino A. Physicians increasingly targeted for unionization. Healthcare Financial Management Association. March 3, 2026. Available at: https://www.hfma.org/fast-finance/physician-unionization-healthcare-2025/
3. Becker’s Physician Leadership. Inside the physician unions, healthcare strikes of 2025. December 29, 2025. Available at: https://www.beckersphysicianleadership.com/physician-workforce/inside-the-physician-unions-healthcare-strikes-of-2025/
4. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(9):901–902. doi:10.1001/jama.2017.0076
   Disclosures: The author reports no conflicts of interest.