Each day on his commute to the clinic, Dr Crister Brady traverses the rolling farmland of Eastern North Carolina, gliding past the neon-green tobacco fields where many of his patients live and work. Brady’s clinic, the Prospect Hill Community Health Center, is one of ten federally qualified health centers operated by Piedmont Health Services Inc. The nonprofit provides comprehensive primary care services to patients who are uninsured or who receive coverage from Medicaid and Medicare.
Brady’s desire to care for underserved communities dates back to his experience providing “street medicine” to the unhoused. Today he aims to use his credibility as a physician to chip away at the artificial divisions designed to separate caregivers from their patients and each other.
Last year, Brady and his physician colleagues linked arms with other providers including physician associates (PAs), nurse midwives, and nurse practitioners (NPs) to form an interprofessional union. Doctors’ unions are rare in the United States — and unions comprised of physicians and other medical providers are even rarer. In March, members of Brady’s union, Piedmont Health Services Medical Providers United, voted 91 percent to form a union, an astounding margin for the country’s second least-unionized state.
Brady and his coworkers are currently negotiating their first union contract. Their demands include increased administrative time for paperwork and charting, improved benefits, and a greater voice in the clinical decision-making process at their workplaces. The providers who spoke to Jacobin drew clear connections between their fight for a more democratic workplace and their devotion to providing quality care for their patients.
“We all come to this work focusing on the communities that we serve,” said Brady:
However, we’re not able to do that if we’re not being well cared for, if we don’t see ourselves as just as important as the communities we serve. It’s something I work toward every day, and I have not found a balance yet, but I think we can work toward it as a union.
To secure their seat at the negotiating table, Piedmont caregivers had to overcome a divisive anti-union campaign as well as deep-seated interprofessional divisions that have long stymied workplace organizing in health care. The story of how the Piedmont providers were able to band together despite tremendous obstacles provides an example for other caregivers seeking to build labor power in their own workplaces.
“We Had to Take It Into Our Own Hands”
The coronavirus pandemic ushered in a wave of labor organizing among resident and house physicians unmatched since the 1970s. Residents with the Committee of Interns and Residents (CIR) scored major union victories at three teaching hospitals in the last six months alone, animated by low wages, long hours, unsafe working conditions, and widespread burnout.
Despite also contending with long working hours and an epidemic of burnout, a comparable union campaign has failed to take root among practicing physicians, let alone advanced practice providers like nurse practitioners and physician associates. According to the Bureau of Labor Statistics, only 11.7 percent of health care practitioners and technical workers claimed union membership in 2021.
Dr Brady’s personal introduction to the power of organized labor began during his residency training at San Francisco General Hospital. He joined the CIR on day one of his first-year medical internship. At the time, Brady and the other residents at the safety-net hospital were overwhelmed by ballooning patient loads and the addition of patient rooms without the necessary staff increases to accommodate them. The residents joined forces with nurses and other health care workers to demand additional staff support.
“Ultimately, it was about creating conditions where we felt safe as residents,” Brady recalled. “And seeing how that affected patient care as well was pretty stark, knowing the hours that we work and the safety issues. We had to take it into our own hands as well.”
The interprofessional collaboration at San Francisco General resulted in the procurement of more advanced practice practitioners to ease the patient load, better coverage on night shifts, and perhaps most important a spirit of solidarity between the residents and the nurses. The experience provided Brady with a model for how to build power that he would draw on again during the union campaign in North Carolina.
Organizing for Survival
Primary care is one of the least glamorous, most poorly compensated, and most under-resourced medical specialties. It’s also one of the most important on account of its focus on preventive care and health maintenance. The United States is projected to experience a primary care physician shortage of 55,200 by 2033, compounded by lower reimbursement rates as well as decreased earning potential for young physicians saddled with six-figure student debt compared to more lucrative specialties like radiology and orthopedic surgery. Doctors and advanced practice providers choose to work in primary care over higher-paying specialties out of a desire to serve patients who have nowhere else to turn.
Piedmont Health Services appeared to be the ideal workplace for providers like Destry Taylor. Growing up in poverty motivated Taylor to become a nurse practitioner so that they could care for the poor. In 2020, Taylor accepted a position at Chapel Hill Community Health Center, North Carolina’s oldest federally qualified health center. Taylor was drawn in part by Piedmont’s sterling reputation for serving members of the LGBTQ community.
Taylor found that reputation mostly warranted but soon encountered other problems stemming from an overall lack of communication and transparency on the part of Piedmont administrators. Taylor and other providers found themselves in the frustrating position of having their suggestions for improving patient care delivery ignored by management while still being forced to treat more people in less time and with insufficient staff and resources.
For example, Taylor complained about resorting to weighing infants in their parent’s arms, which does not result in an accurate measurement, because the Chapel Hill clinic did not have a baby scale. Email and in-person requests for an infant scale went nowhere.
Brady’s experience was similarly frustrating. “I came into this work knowing that it was going to be very hard coming to a state that has not expanded Medicaid, and it would be working with a lot of people without insurance,” Brady said, “and so I was ready for those challenges. But I think seeing some of the inefficiencies and the barriers that our own organization was putting up early on made it pretty obvious that some sort of change needed to happen.”
One day, Taylor received a phone call from Dr Rupal Yu on their drive home. Yu and some of the other providers had concluded that the only way they were going to have a greater voice at their clinics was to form a union. Was Taylor on board?
“I was elated,” Taylor recalled. “I was really reaching my point at Piedmont where I was concerned I wouldn’t be able to continue in primary care just because the workload felt too high and the support felt too low.”
The increased administrative burden heaped on providers threatened to push the caregivers to their breaking points. As more and more providers left or considered leaving Piedmont, it was clear to Taylor, Brady, and the others left behind that the union drive was now a matter of survival in their jobs.
Battling Burnout and Union Busting
Brady arrives thirty minutes early to work each morning to start preparing to see patients, many of whom suffer from complex medical conditions that require extra attention. He continues charting during his lunch break and stays two hours late after an already grueling ten-hour shift so he can review lab work and imaging studies and make referrals. Some providers find other ways to stay afloat, like charting at home when they’re not on the clock or reducing their paid work hours to take care of business.
“A lot of folks are working part-time because they are using their off time to do a lot of this administrative stuff,” said Dr Michaela McCuddy, a physician at the Siler City Community Health Center. “That’s really the only way to balance the demands without working well over full-time.”
Piedmont providers are allotted four hours of administrative time weekly, Brady said, which falls far short of the national standard of two and a half days. Achieving parity with the national standard would relieve a huge burden. “Things like that will help my level of burnout,” Brady said,
because that’ll give me more time to be with my family. It’ll give me more time to prepare for the level of illness that I see in people who have been out of care for many years or have issues with access.
The providers hoped Piedmont would voluntarily recognize the union, given the nonprofit’s commitment to service and its decades-long history of caring for patients struggling to access medical services. Instead, Piedmont administrators contracted Ogletree, Deakins, Nash, Smoak & Stewart, a pricey law firm notorious for its union-busting expertise.
The announcement shocked the providers and dispelled any hope they had for a quick resolution. “Some days of the week, lifesaving vaccines wouldn’t be available because of cost, and they’ve hired this $500-an-hour law firm to represent them,” Brady said. “It feels like an affront to not just us but our patients. Giving them care is the whole reason we’ve unionized.”
Administrators organized captive audience meetings where union busters spread misleading information about how unions reduce workers’ take-home pay and impair communication between management and staff. In the months leading up to the union vote, management circulated a letter underscoring the income disparities between the providers and their support staff in an effort to isolate the providers and to turn their coworkers against them.
“I think if [management] had any argument that stuck, it’s ‘Who are the highest-paid people in your organization?’” said Brady. “Actually, the people sending the email are the highest-paid people in our organization, but they painted the providers as sort of a really privileged class. And of course we are.”
In that same vein, Piedmont Health Services challenged the National Labor Relations Board (NLRB) petition, claiming the providers were ineligible to form a collective bargaining unit on the grounds that they frequently acted in a supervisory capacity and because of the variability in their professional duties.
Despite real differences in their education, training, and compensation, the Piedmont providers were going to have to form a united front in order to prevail.
Crossing the Professional Line
Although they must work shoulder-to-shoulder to care for patients in life-and-death situations, health care workers remain divided from one another along rigid professional lines. Health care workers are grouped according to task, certification, expertise, and education, resulting in a hierarchy that is dizzyingly complex. Much of that hierarchy is determined by education level, with physicians requiring additional schooling and training. The differences are reflected in compensation. According to an NLRB document obtained via Freedom of Information Act request, Piedmont physicians are paid 75 percent more than other advanced practice providers with similar experience.
The difficulty of surmounting interprofessional divisions presents a major obstacle for health care workers interested in taking collective action, which is one reason why the Piedmont providers’ victory is so remarkable. Rather than play into the hands of management and allow themselves to be divided by their professional differences, the NPs, PAs, nurse midwives, and doctors of Piedmont Health Services instead united around the ways their job responsibilities overlapped in primary care — and around their shared commitment to their patients.
“We’re all providers,” said Ben Thompson, a physician associate at the Carrboro Community Health Center. “We’re all there for the same common goal, and that goal is to have the best patient care that we can give to our patients by getting the best support for our providers and staff.” He added, “That crosses all lines of certification and licensure.”
Piedmont medical doctors echoed Thompson during their testimony before representatives of the NLRB, contradicting their employer’s assertion that there was too much variability among the providers’ job responsibilities for them to collectively bargain.
According to testimony delivered during a two-day hearing before the NLRB:
Both Dr. [Adrian] Mancheno and Dr. Rupal Yu, a physician at the Carrboro clinic, testified that within a family practice realm, nurse practitioners and physician assistants can perform the same procedures as physicians.
Dr. Yu testified that she would consult with a colleague based on that colleague’s area of expertise (such as HIV or diabetes) rather than on that colleague’s job title (such as nurse practitioner or physician). All petitioned-for employees use the same exam rooms, equipment, and instruments.
Regional director Lisa Henderson ruled that even though physicians have more education and job training than NPs and PAs, the job responsibilities among the various providers were so similar that the workers were eligible to form a bargaining unit together. Moreover, Piedmont physicians and advanced practice providers failed to meet the job criteria of a supervisor, wrote Henderson, since they do not assign work to their medical assistants.
Members of Piedmont Health Services Medical Providers United are currently negotiating their first contract. They support the idea of eventually expanding the union to include all Piedmont staff, which would strengthen the union and empower the lowest-paid and least-respected workers in the clinic.
Federally qualified health centers like those operated by Piedmont Health Services are the backbone of primary care delivery in the South and throughout the country. If other providers follow the example of the Piedmont union and cross professional lines in order to take collective action, they could help lay the foundation for a worker-led movement to refocus the American health care system away from profit seeking and toward meeting human needs.
“None of us came to work at Piedmont because we were expecting to make an incredible salary,” said Thompson.
“What we did come to Piedmont for was to help the people that are in most need in our society who do not have access to the resources that most people in our society have,” he said:
Our union push really is to get the support there for our providers to give us the tools that we need to do our jobs right and to see every single patient and give them the best chance to have a long, healthy, and happy life.