On February 24, the Wall Street Journal published an intriguing item in its popular ‘Work Week’ feature. Titled “Doctors Unite”, the article reported that the association of machinists of the AFL-CIO, one of the country’s largest trade unions, had organised 800 of the 14,000 private practice physicians in the eastern state of New Jersey. Two days earlier, the New York Times wrote that in California, the state’s medical association decided to consider setting up a union subsidiary to bargain collectively for state-government employed doctors and residents. The 35,000 strong medical association expects to make its decision by May.

Why have doctors, traditionally among the most affluent professionals in the US, begun to ponder joining trade unions? The main reason is that over the past decade, the US has seen the rapid growth of managed care systems – and doctors don’t like them. In an attempt to contain skyrocketing health care costs, big insurance companies have formed large health maintenance organisations for HMOs. These companies sign up patients as members and effectively determine the extent and duration of care they can receive for various medical conditions. In the process, the ability of doctors to make decisions about their patients has been severely curtailed — as have their incomes.

So doctors are in pain, and some are looking to unions to prescribe a cure. New Jersey and California represent just the first stirrings of discontent. Physicians have also attempted to form or join unions in recent months in states like Pennsylvania, Florida, Arizona and Washington. And while doctors turn to unions for support against the might of the HMOs, unions, too, are starting to take notice. Richard Bensinger, organising director of the AFL-CIO, says tat doctor unionisation will be “a big, big effort of local organising in the next few years”.

Still, getting organised has proved difficult for doctors, as Frederick Nahas, a vascular surgeon in the Southern New jersey town of Somer’s Point, has discovered. Nahas last year led a group of 200 doctors in filing an unusual petition before the National Labor Relations Board in Philadelphia, requesting the board to let the United Food and Commercial Workers Union, which organises supermarket workers, represent the doctors in negotiations with AmeriHealth, an HMO that is a subsidiary of Independence Blue Cross of Philadelphia. Though the Board turned down the petition, arguing that the doctors were small business people, the union has said that it will raise the issue before the Board’s national office in Washington, DC.

Patients with poor leg circulation may undergo amputation because the HMOs will not pay for expensive vascular surgery

Despite this, attempts to organise doctors are unlikely to die out because frustration against HMOs runs deep. Nahas and his colleagues accuse HMOs of “practising medicine without a license”, while reducing doctors to de facto employees. John Hoevler, an obstetrician-gynaecologist in Somers Point, told an Associated Press reporter that “HMOs dictate to us how to write our chart notes, how much time you will spend with patients, hours of coverage availability, who can cover your practice when you are gone, how much insurance you will carry and in what form, what specialists you will refer your patients to, what laboratories you will send your lab tests to, what radiologists you must send your patients to for X-rays, what drugs you can and can’t use to treat a particular patient’s disease, when patients have to leave the hospital, and how much you will be paid”. Nahas adds that the HMOs’ represent another source of frustration. For example, the AmeriHealth contract offer doctors a so-called capitation rate for patients. If doctors see a patient more than a certain number of times a year, they lose money because the HMO refuses to reimburse them.

Other doctors say that HMOs push them to provide less-than-adequate treatment to patients in an effort to cut costs. Anthony Tonzola, a general surgeon in Westfield, New jersey, says that sometimes patients with poor leg circulation have to undergo amputation because the HMOs will not pay for expensive treatments like vascular surgery and rehabilitation. Frustrated by this attitude, Tonzola and some 800 colleagues have joined the International Association of Machinists and Aerospace Workers, which is affiliated with the AFL-CIO.

Will these efforts to unionise doctors mean that someday physicians will engage in militant battles against HMOs? Frustrated as many doctors are with managed care and its policies, that scenario seems unlikely. Even if it were possible to overcome the legal hurdles, the doctors are divided over whether unions are the best way to go. “Most doctors are quite well off, and they won’t do anything to jeopardise that,” says a surgeon, more in sorrow than anger. “The problem is that we are all quite individualistic. Trying to organise doctors is like trying to herd cats”. Unless something happens to change that attitude, doctors and unions — despite their occasional flirting – may remain quite far apart.