Why Doctors and Pharmacists Are in Revolt

The New York Times

By Noam Scheiber

Dec. 3, 2023

Once accustomed to a status outside the usual management-labor hierarchy, many health professionals now feel as put upon as any clock-punching worker.

Dr. John Wust does not come off as a labor agitator. A longtime obstetrician-gynecologist from Louisiana with a penchant for bow ties, Dr. Wust spent the first 15 years of his career as a partner in a small business — that is, running his own practice with colleagues.

Long after he took a position at Allina Health, a large nonprofit health care system based in Minnesota, in 2009, he did not see himself as the kind of employee who might benefit from collective bargaining.

But that changed in the months leading up to March, when his group of more than 100 doctors at an Allina hospital near Minneapolis voted to unionize. Dr. Wust, who has spoken with colleagues about the potential benefits of a union, said doctors were at a loss on how to ease their unsustainable workload because they had less input at the hospital than ever before.

“The way the system is going, I didn’t see any other solution legally available to us,” Dr. Wust said.

At the time he and his colleagues voted to unionize, they were one of the largest groups of private-sector doctors ever to do so. But by October, that distinction went to a group that included about 400 primary-care physicians employed in clinics that are also owned by Allina. The union that represents them, the Doctors Council of the Service Employees International Union, says doctors from dozens of facilities around the country have inquired about organizing over the past few years.

And doctors are not the only health professionals who are unionizing or protesting in greater numbers. Health care workers, many of them nurses, held eight major work stoppages last year — the most in a decade — and are on pace to match or exceed that number this year. This fall, dozens of nonunion pharmacists at CVS and Walgreens stores called in sick or walked off the job to protest understaffing, many for a full day or more.

The reasons for the recent labor actions appear straightforward. Doctors, nurses and pharmacists said they were being asked to do more as staffing dwindles, leading to exhaustion and anxiety about putting patients at risk. Many said that they were stretched to the limit after the pandemic began, and that their work demands never fully subsided.

But in each case, the explanation runs deeper: A longer-term consolidation of health care companies has left workers feeling powerless in big bureaucracies. They say the trend has left them with little room to exercise their professional judgment.

“People do feel put upon — that’s real,” said John August, an expert on health care labor relations at the Scheinman Institute at Cornell University. “The corporate structures in health care are not evil, but they have not evolved to the point of understanding how to engage” with health workers.

Allina said that it had made progress on reducing doctors’ workloads and that it was partnering with health care workers to address outstanding issues. CVS said it was making “targeted investments” in pharmacies to improve staffing in response to employees’ feedback, while Walgreens said it was committed to ensuring that workers had the support they needed. Walgreens added that it had invested more than $400 million over two years to recruit and retain staff members.

Professionals in a variety of fields have protested similar developments in recent years. Schoolteachers, college instructors and journalists have gone on strike or unionized amid declining budgets and the rise of performance metrics that they feel are more suited to sales representatives than to guardians of certain norms and best practices.

But the trend is particularly pronounced in health care, whose practitioners once enjoyed platinum-level social status at high school reunions and Thanksgiving dinners.

For years, many doctors and pharmacists believed they stood largely outside the traditional management-labor hierarchy. Now, they feel smothered by it. The result is a growing worker consciousness among people who haven’t always exhibited one — a sense that they are subordinates constantly at odds with their overseers.

“I realized at end of the day that all of us are workers, no matter how elite we’re perceived to be,” said Dr. Alia Sharif, a colleague of Dr. Wust’s at Allina who was heavily involved in the union campaign. “We’re seen as cogs in the wheel. You can be a physician or a factory worker, and you’re treated exactly the same way by these large corporations.”

‘We were all partners.’ Then came the metrics.

The details vary across health care fields, but the trend lines are similar: A before-times in which health care professionals say they had the leeway and resources to do their jobs properly, followed by what they see as a descent into the ranks of the micromanaged.

As a pharmacy intern and pharmacist at CVS in Massachusetts beginning in the late 1990s, Dr. Ed Smith found the stores consistently well staffed. He said pharmacists had time to develop relationships with patients.

Around 2004, he became a district manager in the Boston area, overseeing roughly 20 locations for the company. Dr. Smith said CVS executives were attentive to input from pharmacists — raising pay for technicians if there was a shortage, or upgrading clunky software. “Every decision was based on something that we said we needed,” he recalled.

Dr. Wust looked back on his days in an independent practice of about 25 doctors with a similar wistfulness. “We were all partners,” he said. “It was relative workplace democracy. Everybody got a vote. Everybody’s concerns were heard.”

Over time, however, consolidation and the rise of ever-larger health care corporations left workers with less influence.

As so-called pharmacy benefit managers, which negotiate discounts with pharmacies on behalf of insurers and employers, bought up rivals, retail giants like Walgreens and CVS made acquisitions as well, to avoid losing market power.

The chains closed many of their newly owned locations, driving more customers to existing stores. They sought to cut costs, especially labor costs, as the benefit managers reined in drug prices.

Around 2015, Dr. Smith stepped down from his role as a district manager and became a frontline pharmacist again, reluctant to supervise co-workers under conditions he considered subpar. “I couldn’t ask my pharmacists to do what I couldn’t accomplish,” he said.

Among his frustrations, he said, was the need to strictly limit the number of workers each pharmacy could schedule. “Every week that you’re over your labor budget, you get a call, regardless of prescription volume, from your district manager,” Dr. Smith said. “If your budget for tech hours is 100 and you used 110, you get a phone call. It’s not much money — maybe $180 — but you’re getting a call.”

Asked how labor budgets were applied, CVS said managers were “provided guidance” based on expected volume and other factors, with adjustments made to ensure adequate staffing.

Dr. Smith and other current and former CVS and Walgreens pharmacists said their stores’ allotment of hours for pharmacists and pharmacy technicians had dropped most years in the decade before the pandemic.

The pharmacists also described being held to increasingly strict performance metrics, such as how quickly they answered the phone, the portion of prescriptions that are filled for 90 days rather than 30 or 60 days (longer prescriptions mean more money up front) and calls made urging people to fill or pick up prescriptions.

For years, Walgreens and CVS pharmacists could largely ignore these narrower metrics so long as overall profits and customer satisfaction stayed high. But in the early to mid-2010s, both companies elevated the importance of these indicators, several pharmacists said.

At Walgreens, many pharmacy managers began reporting to a districtwide retail supervisor rather than a supervisor trained as a pharmacist. “It coincided with more pushing of the metrics,” said Dr. Sarah Knolhoff, a Walgreens pharmacist from 2009 to 2022.

“Never having been a pharmacist, they would push the pharmacy the same way they would push the front end,” Dr. Knolhoff added, alluding to the rest of the store.

CVS said that performance metrics were needed to ensure safety and efficiency for patients but that in recent years it had reduced the number of metrics it tracked. Walgreens announced last year that it would no longer rely on “task-based metrics” in performance reviews for pharmacy staff members, though it still used them to track store-level performance.

‘Corporate tells you how to manage your patient.’

The transition for doctors and nurses came around the same time. As independent medical practices found they had lost leverage in negotiating reimbursement rates with insurers, many doctors went in house at larger health systems, which could use their size to secure better deals.

The passing of the Affordable Care Act in 2010, along with federal rule-making efforts, rewarded bigness by tying reimbursement to certain health outcomes, like the portion of patients who must be readmitted. Getting bigger helped a hospital system diversify its patient population, the way an insurer does, so that certain groups of high-risk patients weren’t financially ruinous.

Administrators increasingly evaluated their medical staff according to similar metrics tied to patients’ health and put a variety of incentives and mandates in place.

Doctors and nurses chafed at the changes. “Corporate tells you how to manage your patient,” said Dr. Frances Quee, president of the Doctors Council, which represents about 3,000 doctors, most of them at public hospitals. “You know that’s not how you’re supposed to manage your patient, but you can’t say anything because you’re scared you’re going to be fired.”

At Allina, primary care doctors are given incentives to talk to patients about their high-risk or chronic medical conditions, even if those conditions are well managed and aren’t relevant to a visit.

“Is that a valuable use of our 25 minutes together?” said Dr. Matt Hoffman, a primary care doctor at an Allina clinic that unionized in October. “No, but it means Allina gets more money from Medicare.”

Dr. Wust said hospital administrators increasingly relied on management theories borrowed from other industries, like manufacturing, that sought to minimize excess capacity.

For example, he said, obstetricians at Allina had one or two hold spots a day of 15 minutes each, in case of a patient emergency, when he began working at the system. Several years ago, Allina took away these buffers, instructing obstetricians to double book instead.

Asked about the hold spots, Allina said, “We’re always looking at how we’re using our resources to deliver high-quality care.” It said the incentives tied to high-risk conditions could still be achieved if a doctor stated that the problem was no longer relevant. Dr. Josh Scheck, another Allina primary care doctor, said he found the nudge helpful and not very time consuming to address. He said the health system had allowed his clinic to experiment with ways to make its work flow more efficient.

Other health workers complained that some of the metrics they’re evaluated on, like patient satisfaction, made them feel like retail clerks or dining employees rather than medical professionals.

Adam Higman, an expert on hospital operations at the consulting firm Press Ganey, said consolidation and the increased use of metrics had arisen in response to a need to lower U.S. health care costs, long the world’s highest per capita, and ensure that the spending actually benefits patients.

He pointed to data showing that more empathetic and communicative doctors and nurses — factors that affect patients’ experience — lead to healthier patients.

But Mr. Higman acknowledged that many health systems had increased tensions with doctors and nurses by failing to involve them more in developing and putting in place the system of metrics on which they are judged. “The progressive, smart health systems and medical groups are listening to physicians, looking at their experience and turnover and creating venues to have discussions,” he said. “If not, that’s one of the contributing factors to organizing.”

‘I would not have put unions and physicians in the same mind.’

The pandemic magnified these strains.

As retail chains rolled out Covid-19 vaccines, pharmacists complained of being overworked to the point of skipping bathroom breaks and said they worried constantly about making mistakes that could harm patients. (CVS said it began closing most pharmacies for 30 minutes each afternoon last year to give pharmacists a consistent break. Walgreens said “dedicated pharmacist meal breaks” began in all stores in 2020.)

Doctors and nurses found that their already backed-up inboxes were suddenly bursting, as frightened patients clamored for medical advice. Administrators sought to squeeze more patients into overloaded hospitals and clinics.

The breaking point came when the height of the pandemic passed, but conditions barely improved, according to many workers. Although health systems had promised to add staffing, many found themselves running deficits amid inflation and a shortage of doctors and nurses.

Professionals who had never considered themselves candidates for union membership began to organize. When she started at Allina in 2009, Dr. Sharif said, “I would not have put unions and physicians in the same mind — it would have been a totally alien concept.” She reached out to the Doctors Council last year for help unionizing her colleagues.

Dr. Quee, the union president, said that inquiries from doctors were up more than threefold since the second group of Allina doctors unionized last month — and that as a result, the Doctors Council was hiring more organizers. (Allina is appealing the outcome of the union vote at the hospital but not at its clinics.) Even pharmacists are reaching out. “Two days ago, pharmacists called me from Florida,” she said. “We’ve never done pharmacists before.”

In September, Dr. Smith, who long ago shifted from CVS district manager to frontline pharmacist, took on an additional role: labor organizer. After CVS fired a district manager who had refused to close some stores on weekends to address understaffing, Dr. Smith helped organize a series of coordinated sick days and walkouts in the Kansas City, Mo., area, where he has worked for the company in recent years.

The walkouts affected roughly 20 locations and drew the company’s chief pharmacy officer and a top human resources official to town for a meeting with the renegades. A few weeks later, CVS said it would rein in vaccination appointments and add work hours for pharmacy technicians, though it had not increased their pay.

CVS said several Kansas City-area pharmacists had called in sick on certain days in September, “resulting in about 10 unexpected pharmacy closures” on one day and part of another. In response, it said, executives met with pharmacists to listen to and address their concerns.

During an interview in October, while Dr. Smith and his colleagues were still awaiting the company’s response, he made clear that his patience had run out. “I’ve been asking and asking and asking for improvements for years,” he said. “Now we’re not asking any more — we’re demanding it.”