Photo by Debra DiPaolo
So just the idea of a doctors union was worth a laugh. Yet it was probably the elevated prestige and prevailing remuneration levels that eventually helped to chip away at the American physicians social and economic pedestal. Craving wealth and prestige, hordes of young people trained to be doctors, just as drugs and research were stamping out many diseases and reducing the hazards of others. Since those times, with the exception of the increased need for geriatric care as people live longer, the general demand for doctors has diminished, even as the overall supply has risen. By the 1980s, there were far more Young Doctor Malones out there than the nations private practices could support. And, according to the AMAs figures, nearly every one of those apprentice medicos was carrying $75,000 worth of debt coming out of medical school.
We know what happened. Nowadays, most doctors work with or for HMOs and kindred organizations that supply enough care to keep us in fair health while providing an absolute minimum of human contact. This situation, unsurprisingly, also affects the way doctors think of themselves. Increasingly, they dont feel things are quite the way they ought to be, either.
No longer can they practice medicine as they might wish. Nor are they venerated Dr. Zorbas, living in the biggest homes in town. Instead, physicians are becoming salaried providers of specific services, condemned to years of hard labor to pay off their loans.
Almost exactly like the rest of us employees. And thats why, here and there, union organizing actually has broken out among this formerly most independent sector of Americas professional classes.
Nationally, most of the physician organizing has been undertaken by the Service Employees International Union (SEIU). The International Association of Machinists (IAM), of all unions, has also made some headway organizing doctors in the Northeast. According to our sister publication, The Village Voice, the IAM allows that physicians do indeed make lots of money. But they contend that if super-salaried athletes can be represented against super-rich owners, why cant merely wealthy doctors be represented against HMOs?
In Southern California, though, the Union of American Physicians and Dentists (UAPD), affiliated with the American Federation of State, County and Municipal Employees, has reached out to quite dissimilar practitioners. The union is vying to become the bargaining unit for doctors employed by the Los Angeles County Department of Health Services (DHS). If it wins next months election (ballots are mailed out May 3), the UAPD will represent all of the DHSs 800 doctors one of the largest collections of medical professionals in the state.
But by no means the highest-paid. These public-health physicians earn roughly $80,000 to $130,000 per year. Now, most Angelenos can only aspire to this kind of remuneration, but we are, of course, talking doctors. There are even print journalists in this town not to mention plenty of attorneys and police commanders who make this kind of change.
So were not talking Michael Ovitzclient salaries here. County physicians pay may go up if the UAPD wins the election. But even without full authorization to represent county doctors, the union has already made some notable improvements in the way the DHS relates to its physician employees. Thanks to the unions efforts, it looks as if DHS management is actually having to listen to its doctors, for a change. And this has already affected the recent progress of the DHSs much-vaunted "re-engineering" project.
For a change, I said. Theres long been plenty of talk about employees participating in the DHSs current transmutation. Their input, we were told, was being actively sought. But the doctors Ive talked to agree that this "input" mostly consisted of sitting in little groups and listening to what DHS bigwigs had to say. And apparently few bigwigs listened back. Until now.
Lets not forget that its been three years since the county, facing a huge health-care deficit, cut a deal with the feds that required the DHS to change the way it took care of people. Instead of providing more costly inpatient care (then in decreasing demand), the DHS was allowed to transfer federal funds to outpatient care (for which the demand was increasing). In return, the DHS was supposed to pare its operating expenditures.
But bulky bureaucracies seldom change overnight, so re-engineering has been wayward. Last year, all five county supervisors voiced skepticism that DHS chief Mark Finucane was meeting his scheduled savings goals. And some DHS employees are contending that, due to re-engineerings slow pace, the system is losing patients to private clinics and hospitals.
Meanwhile, one key re-engineering step has been opposed by the doctors themselves. This is the proposed centralization of the countys widely dispersed medical-lab functions. To the supervisors, this proposal seemed, in the words of Zev Yaroslavsky, "a natural." The test processing, now generally done on-site at the various county hospitals, was all to have been completed at just two lab sites. What bothered the doctors was that one of these sites was Olive View Medical Center, far out in the San Fernando Valley. The other, mostly for blood tests, was King-Drew Medical Center, which has a reputation for subpar performance.
"You want the results of a test right away. Sometimes a patients life can depend on it. Sometimes it could take more than two hours [for a county messenger] just to get a sample from UCLA-Harbor to Olive View," objected one county physician, not speaking for attribution. Among those who tendered their objections to Finucane and his associate director, Donald Thomas, M.D., were Dr. Irene Gleason-Jordan, herself a pathologist at King. Dr. Samuel French, a Harbor pathologist, also registered his dismay.
In addition to the time factor and the widespread incredulity as to the ability of K-Ds labs to handle blood work for all five county medical centers, doubts also surfaced as to whether the DHSs balky new computer system could be trusted with test results.
Doctors repeatedly mentioned these problems in re-engineering meetings. But their caveats werent acknowledged until the UAPD, in a July 29 letter, made the consolidation a centerpiece of its organizing efforts. Citing potential "delays, mishaps and problems" and the consequent "greater malpractice liability," the letter concluded: "County physicians deserve to be treated with respect and must be consulted on all matters pertaining to how patient care is delivered . . ."
A DHS spokeswoman, speaking on behalf of Thomas (who did not return my calls), confirmed that the doctors objections had derailed the lab-consolidation plans. Now only surgical-tissue testing may be centralized. Of course, no one at DHS is going to credit the union with this change. Not directly.
But just as the DHS was surrendering on lab consolidation, a new DHS scheme emerged that could hinder the unions organizing campaigns. It has been proposed (in a November 25 board memo from Thomas) that all county doctors earning more than $95,000 a year "be considered as clinical managers." "Managers" would probably be ineligible for union membership.
As the union points out, this "promotion" would, in effect, strip these same doctors of their civil-service protection, and make them serve at the pleasure of DHS management. They could then be fired for making complaints like those that stopped the lab consolidation.
Local UAPD head Joe Bader suggests that county health management may have a larger ulterior plan. Re-engineering, he suggests, could be a step on the way to turning the entire county health-services monolith into a kind of mega-HMO, overseen by retired county doctors. "Then youd have the worst of the private-practice and bureaucratic worlds," he asserts.
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For now, though, it appears that just giving doctors more say in how the DHS is run could actually make the present system work better at least for its patients.
I recently wrote here that Zev Yaroslavsky had had no known union affiliation. I should have asked him. Before he was elected to the City Council nearly 25 years ago, Yaroslavsky says, he had a job cleaning old film cans. And for that he joined the International Association of Theatrical and Stage Employees (IATSE).