June 2021—Several CAP fellows have reached out to me recently about a topic many find controversial: whether pathologists should unionize. Some of this interest stems from concerns about employment models and how pathologists are treated in various situations. Some of it comes from concerns that pathologists are not being compensated appropriately for the risks and responsibilities they bear daily.
The COVID-19 pandemic has also fueled increased interest in unionizing among many types of health care workers. According to the U.S. Bureau of Labor Statistics, people who work in health care and social assistance are a little less likely to belong to unions than people in other fields. In 2020, 7.1 percent of workers employed in health care and social assistance were members of unions, compared with 10.8 percent for people in all industries. But the pandemic has led to an uptick in unionizing interest for many in the health care field, from nurses and respiratory therapists to many other providers as well as physicians.
My great-grandfather was instrumental in bringing the United Mine Workers of America to the coal mines in Appalachia at a time when that was one of the most dangerous jobs in the country. Many miners were paid by the number of tons of coal they dug. The more they dug, the higher the pay. For some, this draws a similarity to the 88305. They felt that decisions concerning not only their worth but also their well-being were being made by outside interests whose focus was strictly profit. Does this sound familiar? They needed a union.
The face of unions has changed a great deal since those days. Police have unions. Teachers have unions. While many still associate unions strictly with occupations such as coal mining, it is worth remembering that some of the highest-paid people in the world—professional athletes, for example—are union members. They have their own agents but still are unionized.
For pathologists, there are two key questions to consider as we discuss this topic. The first is more straightforward: Can we? The second and more important question: Should we?
For an increasing number of pathologists, I believe the answer to “Can we?” is absolutely yes, if you’re employed. This typically means you are being paid a salary reported on a W-2 form. Pathologists who are supervisors are excluded. If you truly have the capacity to make employment decisions, then you probably won’t be able to be a member. In many cases, interns, residents, and fellows can. For other pathologists, the answer is no. My group is an independent contractor with insurance companies, which would disqualify us from forming or joining a union. The most important regulations in regard to this issue are the antitrust ones that the Federal Trade Commission and the Department of Justice enforce, and they do enforce them. You can negotiate for your group, but you can’t call the other group across town and ask how much they charge or are getting paid by the Blues for an 88305. This is one reason why I believe larger groups will, in the future, have an advantage. Still, more and more pathologists are becoming employees rather than independent practitioners, consultants, or contractors.
In addition, the current U.S. government administration is friendly to unions, making these organizations more powerful. While pathologists’ interest in unionizing is still a minority position, the concept is more possible now than ever.
Which brings us to the second and key question: Should we? The most important measure of this would be whether forming a union would benefit our patients. Some argue that teachers unions have in some ways significantly hurt students. I do not know whether unionizing would hurt our patients, but you can bet I would not support a union if I thought it could have a harmful effect on the people we are responsible for taking care of every day (primum non nocere).
We also have to consider whether we have the temperament to be in a union. Many pathologists, including me, are fiercely independent. Aside from my patients, in the end, the only people I truly work for are the other pathologists and staff in my group and me. Unionizing would cost pathologists a significant amount of that independence, and that’s an important factor to think about.
Right now, the closest thing pathologists have to a union is the CAP. While the CAP cannot negotiate individual contracts and do some of the other things a union does for its members, it does have the ability to lobby on behalf of pathologists and speak for us to elected officials about regulations, laws, and other matters that concern us and our patients. It keeps us informed about what is happening in the states and in Washington. In truth, a great deal of the income we enjoy is because of the hard and successful work of the CAP.
But if you find yourself in a situation where you can no longer serve your patients well or do your best for them, then avenues for change need to be pursued. Words such as burnout come to mind. A union may be one of those avenues, and it may be time that we as a community had a level-headed conversation about that. But it may well be that alternative avenues would be more effective ways to bring about the changes we want faster and better than unionization would permit, so it’s important that we continue to include those in the conversation as well.
Dr. Godbey welcomes communication from CAP members. Write to him at president@cap.org.