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Medical Ethics |

Physician StrikesPhysician Strikes FREE TO VIEW

Stephen L. Thompson, PhD; J. Warren Salmon, PhD
Author and Funding Information

From the Department of Social and Behavioral Sciences (Dr Thompson), National Louis University, Skokie; and the School of Public Health (Dr Salmon), University of Illinois at Chicago, Chicago, IL.

CORRESPONDENCE TO: Stephen L. Thompson, PhD, National Louis University, 5202 Old Orchard Rd, Ste 300, Skokie, IL 60077; e-mail: sthompson@nl.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):1369-1374. doi:10.1378/chest.13-2024
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Throughout medical history, physicians have rarely formed unions and/or carried out strikes. In a profession faced with the turmoil of health reform and increasing pressure to change their practices and lifestyles, will physicians resort to unionization for collective bargaining, and will a strike weapon be used to fight back against the array of corporate and government powers involved in the transformation of the American health-care system? This article examines the question of whether there could be such a thing as an ethical physician strike. Although physicians have not historically used collective bargaining or the strike weapon, the rapidly changing practice environment in the United States might push physicians and other health-care professionals toward unionization. This article considers the ethical questions that would arise if physicians started taking advantage of labor laws, and it lays out criteria for an ethical strike.

Figures in this Article

Today, the medical profession seems in a heightened state of discontent, but physicians’ chosen directions to fight back over their conditions of labor have appeared varied, blurry, and seemingly ineffective. In the United States, marketplace schemes in health care; corporate and governmental cost-containment strategies; clinical scrutiny by nonclinical personnel; and administrative dominance imposed under managed-care firms, federal, and state governments; and accountable care organizations are rattling physicians as rapid and significant change assaults their practices and lives. Braverman1 described such conditions almost 40 years ago as rationalization; that is, a continuous change in the labor process such that the unity of conception and execution is dissolved. Today clinical decision-making and practice are being increasingly rationalized—even beyond what may have been predicted a decade ago.

The predominant independent practice model of the past is quickly going away. As Thompson and Salmon2 have pointed out, the trend is for physicians to lose their status as independent practitioners and find themselves in traditional employer-employee relationships. As a result of that shift, physicians will now be held to externally imposed organizational performance standards that may put them at odds with upholding their Hippocratic obligations. Employment in most of these organizations is “at will,” meaning that an employee can be hired and fired at will for good, bad, or no reason at all; therefore, employee physicians are now at serious risk of being disciplined or terminated suddenly without recourse. While there are public policy exemptions to this doctrine, which might theoretically protect an employee physician from an at-will discharge, employee physicians still have little effective leverage against those powers now arrayed against them.3 There are numerous incidents of employers bullying practitioners, such as removing them from practice panels, interfering in the physician/patient relationship for business purposes, and using economic credentialing by hospitals.4,5,6 While there might be some erosion of the at-will concept, physician employees remain at significant risk for unjust discharge as a result of honoring their ethical duties to provide the best patient care possible without regard to other organizational imperatives, such as cost containment, revenue generation, and quality performance measures.

Thus, given these significant changes in physician practice conditions, could collective bargaining and striking ever be considered ethical under a physician’s duty to do no harm? Given current health-care organizational imperatives, we believe physicians, in a bid to reassert their professional authority, could withhold their labor to reduce harm to future patients at the possible expense of current patients.

Unions and collective bargaining can rebalance the power structure between employee physicians and their employers, and protect employee physicians from unfair treatment by their employers. A 2010 Physicians Foundation Report stated that in response to the Patient Protection and Affordable Care Act, “most physicians will be compelled to consolidate with other practitioners, become hospital employees, or align with large hospitals and health systems for capital, administrative and technical resources.”7 Rosenthal8 echoes this by stating, “American physicians, worried about changes in the health care market, are streaming into salaried jobs with hospitals. Though the shift from private practice has been most pronounced in primary care, specialists are following.” Now that the Affordable Care Act is enrolling patients, this movement toward employee positions has increased.9 We believe this movement toward becoming an employed physician will significantly increase the rationalization of the profession, just as Braverman1 describes.

It should be noted here that physicians who remain independent are unable to organize for the purpose of collective bargaining, since there is no clearly defined employer-employee relationship. In addition, independent practitioners who engage in any collective bargaining activity have been found to be engaging in an illegal restraint of trade, under the Sherman Antitrust Act.10 Therefore, a change in physicians’ employment status from independent practitioner to employee could open the door for them to legally engage in collective bargaining.

Historically, collective bargaining by physicians has arisen under many situations, but most efforts did not advance, or these instances were quelled in various ways.11 Of the approximately 878,194 American physicians in practice today, roughly 50,000 may belong to unions and another 100,000 may be eligible to join unions due to their employment status.1214 In 1935, the National Labor Relations Act (NLRA, more commonly known as the Wagner Act) guaranteed most private-sector workers the right to unionize and bargain collectively, and it did not exclude health-care workers.15 Amended in 1947 by the Taft-Hartley Act, health-care workers of nonprofit hospitals were prohibited from forming unions and engaging in collective bargaining, but by 1974, this specific exclusion was repealed with a specific 10-day advanced written notice requirement needed prior to any strike action.15 While physicians have legally been able to strike, most physicians (particularly those who are employed in teaching hospitals) are often considered supervisors under the law and, thus, not eligible to collectively bargain because of restrictive interpretations by the courts.16 But for those physicians who can engage in collective bargaining, no increase in activity has been seen. The major sticking point may be that collective bargaining leads to strikes, and striking for any reason is seen as a gross violation of a physician’s code of ethics. An advocacy blog on the American College of Physicians website reaffirmed the group’s code of ethics, in that “strikes, boycotts, and other collective actions to deny care to patients or to inconvenience them are flat out unethical.”17

The main thrust of this article is to examine the ways that physicians can appropriately use a strike weapon within the collective bargaining relationship to regain the professional control and autonomy they appear to have lost, without violating their ethical duty to cause no harm. Another way to address the question is to ask what constitutes an ethical physician strike, as we observe the trajectory of the profession’s discontent with the externally imposed conditions of medical practice.

Strikes or work stoppages are tactics that unions use to extract concessions from management during the collective bargaining process. Strikes are most often used to cause the employer economic harm; however, they are also viewed as a failure of the collective bargaining process.

Overall, union membership in the United States has declined from a high of 40% of the work force in the mid-1950s to roughly 11% today.18 Of that 11%, 6.6% of the private sector is unionized, while 36% of the public sector is unionized. Consequently, industrial worker strikes in the United States have diminished considerably, with strikes among physicians being rare (Fig 119).

Figure Jump LinkFigure 1 –  Work stoppages in the United States, 1960-2010.19Grahic Jump Location

As the number of strikes among workers has diminished since 1960, it might be suggested that the more recent strikes by unions were for unions choosing to strike under desperate conditions, as a form of protest, or both. Unfortunately for a large number of these union members, strikes have led to permanent unemployment and replacement of the strikers at the workplace. President Ronald Reagan’s firing of the air traffic controllers in the early 1980s is an example of how work disputes are handled by employers. Corporate entities, including those in health care, routinely push back against workers and their unions in emboldened ways with little response from the state and federal agencies designed to protect union members’ rights to collectively bargain. As a result, strikes in the workforce have become less and less common as the risk of adverse employment outcomes has increased, especially in a recessionary economy with high unemployment.

In the medical context, a strike would be considered a refusal to treat the very population that physicians wish to serve: the patient. Protecting patients’ interests is the primary argument used by the parties to any health-care labor dispute to support their position in bargaining.20 However, strikes by both physicians and other health-care workers that have occurred were mainly over concerns for the practitioner’s own welfare and, secondly, over concern for their patients.21 The lesson here is that one must be ever mindful of public backlash such that patient-care concerns are touted as the sole reason for any job actions. Table 12231 documents a sample of physician strikes that have occurred in North America over the past 50 years and their outcomes.

Table Graphic Jump Location
TABLE 1 ]  Physician Strikes in North America

NYC = New York City.

a 

California was one of the first states in the nation to cap damages for pain and suffering in 1975, which precedes this strike action.

In reviewing the strike actions in Table 1, it appears that those strikes deemed successful had the support of all physicians involved, as well as the public they served. In the heavily unionized, professional sector of public school teachers, militant attitudes occurred most often when they were dissatisfied with their supervision and felt little control over their jobs.32 This would appear to mirror the employee physician’s lot. But unlike school teachers who inconvenience students and their parents by going out on strike, it would seem the stakes for causing greater harm appear higher if physicians and other health-care practitioners use the strike weapon. Concern for patient welfare raises the question of whether striking can be permissible and under what certain circumstances.

This contradiction between professional self-interest and patients’ welfare varies depending upon one’s point of view. When physicians within an organization are treated badly, it should be clearly understood by most observers that this treatment would lead to substandard patient care. Strikes that bring about higher pay and better treatment of professionals might conceivably yield improved morale and, thus, better patient care; however, we are unaware of any studies that correlate physician remuneration with patient-care quality. Higher prices do not equal higher quality: Recent data point out those higher-cost hospitals have not been shown to be of higher quality in terms of health outcomes.33,34

So the ethical issue over whether physicians should strike or not centers on the long-term benefits to the populations’ health and whether they may outweigh short-term losses to the present patient populations. In other words, is a short-term disruption in care necessary and justified to benefit future patients?

If there is such a thing as an ethical physician strike, then one needs to investigate such actions on patient morbidity and mortality. James27 examined the 1976 Los Angeles County physician strike, where elective surgery was abandoned and only emergency surgeries continuing. He found that 55 to 154 deaths did not occur as a result of elective surgery being postponed during the strike. This study seems to refute the assertion that physician strikes are inherently harmful to the population and must be avoided by all means.27 Cunningham et al35 have analyzed a number of physician strikes and came up with similar conclusions, reporting that physicians’ strikes reduce patient deaths from elective procedures and that when these elective surgeries restart, so does the increase in deaths from those procedures. However, a brief anecdotal report in The Lancet in 200636 supports the widely held believe that these actions are harmful, when it blamed a patient’s death on a physician strike at a University Hospital in Central Germany. While it is difficult to know for sure if the strike was the cause of that death, publicity such as this cannot help physicians make their case that any strike is justified for a future of improved, safer health care. Thus, further research on any short-term harm caused by strikes may be advisable to help mitigate any deleterious effects that may result from the tradeoff of possible harm to current patients at the prospect of improved health care for future patients.

But sometimes a strike is not necessary. The mere threat of a strike can be a potent weapon, as Badgley and Wolfe22 surmised in their study of the Saskatchewan physician strike of 1962. They also noted that unless the public is fully behind professionals and their case is clearly portrayed as improving patient care, use of the strike weapon may inevitably backfire and cause more harm than good. To reiterate, the outcomes highlighted in Table 1 seem to reinforce this notion of public support being paramount to the success of any strike by physicians.

Sixty-three percent of physicians indicated in 1979 that they were in favor of physicians organizing, though only 55% thought they should be allowed to strike and a smaller number (46%) said that they would participate in a strike if they all agreed with the issues that led to the strike.37 Most physicians in a Chicago public hospital accepted that if he/she were going to join a union, the union needed the strike weapon for success in the collective bargaining process.11 It would seem that given the current state of medical practice, it might be reasonable to infer that those percentages in favor of collective bargaining and striking listed above have not decreased over time. A study of Israeli medical students may support this finding: 97% believed that striking is a legitimate tool for physicians, and 43% said the suffering of patients caused by the strike was totally or near totally justified.38 This reinforces the outcomes from Table 1, which indicate if a decision is made to strike, the physicians who support that action must be unified in that support. As an example, the British Medical Association does support striking, but its members have had difficulty enforcing their demands, due to a significant amount of physician apathy toward the use of the strike weapon.39

Thomasma and Hurly40 suggest the following criteria for the conduct of ethical strikes in health-care organizations: follow the law and provide 10-day notice under the NLRA and demonstrate this to the larger public; maintain that improving patient care is the primary motive for the strike action; report that all other avenues have been exhausted; provide that emergency patient conditions will be cared for and not abandoned; assure that all current patients hospitalized will be cared for and not abandoned; and relay that the terms for ending the strike will be subject to public scrutiny and further discussion.40 Ultimately, it is the public as health-care consumers that determine the success or failure of any job actions that physicians may take, including a strike. Any strike action should be carefully considered to also include determining the level of public and professional support before, during, and after such an action. Without widespread physician and public support, any strike will be doomed.

Few policymakers and observers currently predict that physician unions will be the wave of the future. Nevertheless, physicians in the United States have always been distrustful of government interference in their affairs, even though they seem to have severely lagged in noticing that the encroachment of the corporate sector was doing much more to undermine their professional well being and ability to practice medicine.41 As increasing cost control and quality monitoring moves forward, it is likely that physician discontent will rise even further.

This transformation of the health-care system needs advocates for improved patient-care quality for the American population, and physicians are uniquely positioned to be that advocate. It is likely that some physicians will resort to unionization for collective bargaining and the use of a strike weapon to fight back against the array of corporate and government powers aligned against them. If the American public shares the same dissatisfactions with health-care access, quality, and cost issues as the medical profession, then physicians will gain sufficient power to fight back with the unity of patients and the public behind them.

As more and more physicians become employees within health-care organizations, their individual options to determine their professional futures will likely diminish, but their status as employees under the NLRA, as well as state and local labor statutes and the ability to collectively bargain, may become greater. This will then lead to consideration of the more difficult decision on whether to unionize (if possible) and whether to use the strike weapon to further goals of gaining back most of what they believe they have lost. Ultimately, the use of the strike tool is really a choice between potential harm to patients in the immediate term vs longer-term quality improvement in patient care for the future. When this tradeoff becomes acceptable to physicians and the public, striking becomes a possible tool to use in supporting their interests in collective bargaining.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Braverman H. Labor and Monopoly Capital. New York, NY: Monthly Review Press; 1974.
 
Thompson SL, Salmon JW. Strikes by physicians: a historical review toward an ethical evaluation. Int J Health Serv. 2006;36(2):331-354. [CrossRef] [PubMed]
 
Muhl CJ. The employment-at-will doctrine: three major exceptions. Monthly Labor Report. 2001(1);3-11.
 
Stearns CA. Physicians in restraints: HMO gatekeepers and their perceptions of demanding patients. Qual Health Res. 1991;1(3):326-348. [CrossRef]
 
Black SB, Evans RW. Economic credentialing of physicians by insurance companies and headache medicine. Headache. 2012;52(6):1037-1040. [CrossRef] [PubMed]
 
Dallet B. Economic credentialing: your money or your life! Health Matrix Clevel. 1994;4(2):325-363. [PubMed]
 
Miller P, Thrall TH. Health reform and the decline of physician private practice – a white paper examining the effects of the patient protection and affordable care act on physician practices in the United States. The Physicians Foundation & Merritt Hawkins website. http://www.physiciansfoundation.org/healthcare-research/health-reform-and-the-decline-of-physician-private-practice-2010/. Published 2010. Accessed March 2, 2014.
 
Rosenthal E. Apprehensive, many doctors shift to jobs with salaries. New York Times. February 13, 2014. http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html?_r=0. Accessed March 2, 2014.
 
Goodnough A. New law’s demands on doctors have many seeking a network. New York Times. March 2, 2014. http://www.nytimes.com/2014/03/03/us/new-laws-demands-on-doctors-have-many-seeking-a-network.html. Accessed March 2, 2014.
 
Goldfarb v. Virginia State Bar, 421 US 773 (1975).
 
Thompson SL, Salmon JW. Physician collective bargaining in a US public hospital. Int J Health Serv. 2003;33(1):55-76. [CrossRef] [PubMed]
 
Active physicians and nurses by state. Physician characteristics and distribution in the US Chicago. Table 165. In:Statistical Abstract of the United States 2012, Washington, DC: US Census Bureau; 2009.
 
Fabrizio NA. Employing physicians: the future is now.. In: Healthcare Trends and Implications 2012-2017. Chicago, IL: Health Administration Press; 2012.
 
Young A, et al. A census of actively licensed physicians in the United States, 2012. Journal of Medical Regulation. 2013;(99)2:11-23.
 
National Labor Relations Act; 29 USC §§ 151-169.
 
Yeshiva University v. NLRB, 444 US 672 (1980).
 
Doherty B. The ACP Advocate Blog. American College of Physicians website. http://advocacyblog.acponline.org/2012/01/physician-strikes-cant-be-justified-to.html. Accessed July 30, 2013.
 
U.S. Bureau of Labor Statistics. Union Members in 2012. Washington, DC: US Department of Labor; 2013.
 
Work stoppages: 1960 to 2010. US Bureau of Labor Statistics, Major Work Stoppages in 2003. News, USDL 04-418. Table 637. In:The 2012 Statistical Abstract of the United States. Washington, DC: US Census Bureau; 2010.
 
Loewy EH. Of healthcare professionals, ethics, and strikes. Camb Q Healthc Ethics. 2000;9(4):513-520. [CrossRef] [PubMed]
 
Jackson RL. Physician strikes and trust. Camb Q Healthc Ethics. 2000;9(4):504-512. [CrossRef] [PubMed]
 
Badgley RF, Wolfe SM. Doctors’ Strike – Medical Care and Conflict in Saskatchewan. Toronto, Canada: MacMillan; 1967.
 
Keith SN. Collective bargaining and strikes among physicians. J Natl Med Assoc. 1984;76(11):1117-1121. [PubMed]
 
Baer N. Despite some PR fallout, proponents say MD walkouts increase awareness and may improve health care. CMAJ. 1997;157(9):1268-1271. [PubMed]
 
Housestaff win patient care improvements: Freedman’s Hospital, Washington, DC. New Physician. 1975;24(2):17.
 
Harmon RG. Intern and resident organizations in the United States: 1934-1977. Milbank Mem Fund Q Health Soc. 1978;56(4):500-530. [CrossRef] [PubMed]
 
James JJ. Impacts of the medical malpractice slowdown in Los Angeles County: January 1976. Am J Public Health. 1979;69(5):437-443. [CrossRef] [PubMed]
 
Budrys G. When Doctors Join Unions. Ithaca, NY: Cornell University Press; 1997.
 
Kravitz RL, Shapiro MF, Linn LS, Froelicher ES. Risk factors associated with participation in the Ontario, Canada doctors’ strike. Am J Public Health. 1989;79(9):1227-1233. [CrossRef] [PubMed]
 
Walker A. East Coast doctors stronger after strike. Medical Post. January 23, 2001; p. 37.
 
Jones T. Surgeons’ strike over insurance splits W.Va. Chicago Tribune. January 4, 2003.
 
McClendon JA, Klaas B. Determinants of strike-related militancy: an analysis of a university faculty strike. Industrial and Labor Relations Review. 1993;46(3):560. [CrossRef]
 
Meier B, McGinty JC. Creswell J. Hospital billing varies wildly, government data shows. New York Times. May 8, 2013. http://www.nytimes.com/2013/05/08/business/hospital-billing-varies-wildly-us-data-shows.html. Accessed March 2, 2014.
 
Medicare provider charge data. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html. Accessed July 30, 2013.
 
Cunningham SA, Mitchell K, Narayan KM, Yusuf S. Doctors’ strikes and mortality: a review. Soc Sci Med. 2008;67(11):1784-1788. [CrossRef] [PubMed]
 
Chapman C. Doctors’ strikes blamed for patient’s death in Germany. Lancet. 2006;368(9531):189. [CrossRef] [PubMed]
 
Wassertheil-Smoller S, Croen L, Siegel B. Physicians’ changing attitudes about striking. Med Care. 1979;17(1):79-85. [CrossRef] [PubMed]
 
Lachter J, Lachter L, Beiran I. Attitudes of medical students to a physicians’ strike. Med Teach. 2007;29(4):411. [CrossRef] [PubMed]
 
Praities N. Low turnout blunts protest. Pulsetoday.co.uk. 2012;72(23):9.
 
Thomasma DC, Hurley RM. The ethics of health professional strikes.. In:Moanagle JM, Thomasma DC., eds. Medical Ethics-A Guide for Health Professionals. Rockville, MD: Aspen Publishing; 1988.
 
Salmon JW, White WD, Feinglass J. The futures of physicians: agency and autonomy reconsidered.. In:Salmon JW., ed. The Corporate Transformation of Health Care, Part II: Perspectives and Implications. Amityville, NY: Baywood Publishing Company; 1994.
 

Figures

Figure Jump LinkFigure 1 –  Work stoppages in the United States, 1960-2010.19Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Physician Strikes in North America

NYC = New York City.

a 

California was one of the first states in the nation to cap damages for pain and suffering in 1975, which precedes this strike action.

References

Braverman H. Labor and Monopoly Capital. New York, NY: Monthly Review Press; 1974.
 
Thompson SL, Salmon JW. Strikes by physicians: a historical review toward an ethical evaluation. Int J Health Serv. 2006;36(2):331-354. [CrossRef] [PubMed]
 
Muhl CJ. The employment-at-will doctrine: three major exceptions. Monthly Labor Report. 2001(1);3-11.
 
Stearns CA. Physicians in restraints: HMO gatekeepers and their perceptions of demanding patients. Qual Health Res. 1991;1(3):326-348. [CrossRef]
 
Black SB, Evans RW. Economic credentialing of physicians by insurance companies and headache medicine. Headache. 2012;52(6):1037-1040. [CrossRef] [PubMed]
 
Dallet B. Economic credentialing: your money or your life! Health Matrix Clevel. 1994;4(2):325-363. [PubMed]
 
Miller P, Thrall TH. Health reform and the decline of physician private practice – a white paper examining the effects of the patient protection and affordable care act on physician practices in the United States. The Physicians Foundation & Merritt Hawkins website. http://www.physiciansfoundation.org/healthcare-research/health-reform-and-the-decline-of-physician-private-practice-2010/. Published 2010. Accessed March 2, 2014.
 
Rosenthal E. Apprehensive, many doctors shift to jobs with salaries. New York Times. February 13, 2014. http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html?_r=0. Accessed March 2, 2014.
 
Goodnough A. New law’s demands on doctors have many seeking a network. New York Times. March 2, 2014. http://www.nytimes.com/2014/03/03/us/new-laws-demands-on-doctors-have-many-seeking-a-network.html. Accessed March 2, 2014.
 
Goldfarb v. Virginia State Bar, 421 US 773 (1975).
 
Thompson SL, Salmon JW. Physician collective bargaining in a US public hospital. Int J Health Serv. 2003;33(1):55-76. [CrossRef] [PubMed]
 
Active physicians and nurses by state. Physician characteristics and distribution in the US Chicago. Table 165. In:Statistical Abstract of the United States 2012, Washington, DC: US Census Bureau; 2009.
 
Fabrizio NA. Employing physicians: the future is now.. In: Healthcare Trends and Implications 2012-2017. Chicago, IL: Health Administration Press; 2012.
 
Young A, et al. A census of actively licensed physicians in the United States, 2012. Journal of Medical Regulation. 2013;(99)2:11-23.
 
National Labor Relations Act; 29 USC §§ 151-169.
 
Yeshiva University v. NLRB, 444 US 672 (1980).
 
Doherty B. The ACP Advocate Blog. American College of Physicians website. http://advocacyblog.acponline.org/2012/01/physician-strikes-cant-be-justified-to.html. Accessed July 30, 2013.
 
U.S. Bureau of Labor Statistics. Union Members in 2012. Washington, DC: US Department of Labor; 2013.
 
Work stoppages: 1960 to 2010. US Bureau of Labor Statistics, Major Work Stoppages in 2003. News, USDL 04-418. Table 637. In:The 2012 Statistical Abstract of the United States. Washington, DC: US Census Bureau; 2010.
 
Loewy EH. Of healthcare professionals, ethics, and strikes. Camb Q Healthc Ethics. 2000;9(4):513-520. [CrossRef] [PubMed]
 
Jackson RL. Physician strikes and trust. Camb Q Healthc Ethics. 2000;9(4):504-512. [CrossRef] [PubMed]
 
Badgley RF, Wolfe SM. Doctors’ Strike – Medical Care and Conflict in Saskatchewan. Toronto, Canada: MacMillan; 1967.
 
Keith SN. Collective bargaining and strikes among physicians. J Natl Med Assoc. 1984;76(11):1117-1121. [PubMed]
 
Baer N. Despite some PR fallout, proponents say MD walkouts increase awareness and may improve health care. CMAJ. 1997;157(9):1268-1271. [PubMed]
 
Housestaff win patient care improvements: Freedman’s Hospital, Washington, DC. New Physician. 1975;24(2):17.
 
Harmon RG. Intern and resident organizations in the United States: 1934-1977. Milbank Mem Fund Q Health Soc. 1978;56(4):500-530. [CrossRef] [PubMed]
 
James JJ. Impacts of the medical malpractice slowdown in Los Angeles County: January 1976. Am J Public Health. 1979;69(5):437-443. [CrossRef] [PubMed]
 
Budrys G. When Doctors Join Unions. Ithaca, NY: Cornell University Press; 1997.
 
Kravitz RL, Shapiro MF, Linn LS, Froelicher ES. Risk factors associated with participation in the Ontario, Canada doctors’ strike. Am J Public Health. 1989;79(9):1227-1233. [CrossRef] [PubMed]
 
Walker A. East Coast doctors stronger after strike. Medical Post. January 23, 2001; p. 37.
 
Jones T. Surgeons’ strike over insurance splits W.Va. Chicago Tribune. January 4, 2003.
 
McClendon JA, Klaas B. Determinants of strike-related militancy: an analysis of a university faculty strike. Industrial and Labor Relations Review. 1993;46(3):560. [CrossRef]
 
Meier B, McGinty JC. Creswell J. Hospital billing varies wildly, government data shows. New York Times. May 8, 2013. http://www.nytimes.com/2013/05/08/business/hospital-billing-varies-wildly-us-data-shows.html. Accessed March 2, 2014.
 
Medicare provider charge data. Centers for Medicare and Medicaid Services website. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html. Accessed July 30, 2013.
 
Cunningham SA, Mitchell K, Narayan KM, Yusuf S. Doctors’ strikes and mortality: a review. Soc Sci Med. 2008;67(11):1784-1788. [CrossRef] [PubMed]
 
Chapman C. Doctors’ strikes blamed for patient’s death in Germany. Lancet. 2006;368(9531):189. [CrossRef] [PubMed]
 
Wassertheil-Smoller S, Croen L, Siegel B. Physicians’ changing attitudes about striking. Med Care. 1979;17(1):79-85. [CrossRef] [PubMed]
 
Lachter J, Lachter L, Beiran I. Attitudes of medical students to a physicians’ strike. Med Teach. 2007;29(4):411. [CrossRef] [PubMed]
 
Praities N. Low turnout blunts protest. Pulsetoday.co.uk. 2012;72(23):9.
 
Thomasma DC, Hurley RM. The ethics of health professional strikes.. In:Moanagle JM, Thomasma DC., eds. Medical Ethics-A Guide for Health Professionals. Rockville, MD: Aspen Publishing; 1988.
 
Salmon JW, White WD, Feinglass J. The futures of physicians: agency and autonomy reconsidered.. In:Salmon JW., ed. The Corporate Transformation of Health Care, Part II: Perspectives and Implications. Amityville, NY: Baywood Publishing Company; 1994.
 
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