Collective bargaining may help protect physicians’ rights in a commoditized healthcare system

Healthcare in the United States continues to evolve rapidly, driven by the rise of a consumer-focused delivery model. The increased commodification of the healthcare system has resulted in diminished physician autonomy, increased administrative demands, and constrained decision-making. These trends have contributed to a significant rise in physician burnout across numerous specialties, with the percentage of physicians reporting at least one symptom of burnout rising from 38.2 percent in 2020 to 62.8 percent in 2021. Across the board, physicians often cite administrative burden, loss of schedule control, and productivity demands as drivers of burnout. Many also report decreased satisfaction due to a perceived loss of academic and clinical autonomy and increased administrative workload that detracts from time spent on patient care, research, or teaching.

Orthopaedic surgeons are increasingly seen as revenue generators, with institutional systems prioritizing volume and productivity over individualized care. In orthopaedic surgery specifically, burnout rates remain high, with 45 percent of surgeons reporting symptoms of burnout.

Given these recent trends in burnout, work conditions, and concerns for the quality of patient care, young physician residents have tried to take more control, as shown by increased interest in unionization. However, the relevance of unionization is not limited to trainees. Practicing orthopaedic surgeons face a complex set of systemic pressures, including non-negotiable contracts, inequities in call burden, unrealistic targets for relative value units, and accelerated discharge expectations, which are all shaped by institutional financial priorities. In this context, unionization — specifically collective bargaining — presents a potential path to reclaim authority, protect patient care, and improve surgeon well-being.

At the foundation of these issues is the growing consolidation of healthcare. Between 2012 and 2022, the percentage of physician practices owned by hospitals more than doubled from 23.4 percent to 52.1 percent. Simultaneously, mergers among insurance companies and large health systems have shifted decision-making power away from clinicians and into the hands of administrators and executives. In this system, hospital-employed physicians often are subject to centralized policies that prioritize cost control and throughput over individual clinical judgment.

One of the most visible outcomes of this shift has been the rise of value-based payment structures, such as accountable care organizations, which were designed to shift away from fee-for-service models and instead reward physician groups for delivering cost-efficient, value-based care. However, the regulations and documentation requirements associated with the transition to this approach have placed greater financial and administrative demands on orthopaedic surgeons, often forcing smaller independent practices to merge with larger hospital systems. These administrative demands are particularly difficult for orthopaedic surgeons, whose workflow depends heavily on OR scheduling, case complexity, and volume.

Federal policy has further compounded these pressures. The Health Information Technology for Economic and Clinical Health Act of 2009 aimed to improve care coordination through widespread adoption of electronic health records. Although well-intentioned, this transition imposed significant costs on smaller practices, making independent operation increasingly unsustainable. Many smaller practices could not compete with the cost burden and considered buyout, consolidation, hospital alignment, or employment. As a result, today’s surgeons spend more than twice as much time on documentation and electronic health record tasks than on patient care. For orthopaedic surgeons, this can limit efficiency; increase frustration; and reduce time for innovation, surgery, and education.

A union structure would allow surgeons to collectively push back against these trends and advocate for reduced non-clinical workload, realistic performance expectations, and greater control over clinical decision-making.

Collective bargaining and unionization in orthopaedics
Collective bargaining offers a structured framework for addressing systemic challenges through negotiated agreements between physicians and their employers. Historically used to secure fair compensation and job protections in fields such as education, the model has gained traction in medicine as physicians seek to regain control over their working conditions. Legislative shifts, such as the Quality Health-Care Coalition Act of 2000 and provisions under the National Labor Relations Act, now allow physicians, including orthopaedic surgeons, to collectively negotiate with health systems and insurers.

For orthopaedic surgeons employed by academic medical centers, hospital systems, or corporate groups, unionization presents a pathway to negotiate target compensation thresholds, call-burden distribution, protected block time, and preservation of research and teaching responsibilities. These are domains where administrative priorities frequently override surgical practice goals. Transparency in contract terms and case-scheduling metrics would support both physician well-being and patient care.

Lessons from resident unionization and limitations
Resident unions, such as the Committee of Interns and Residents, have greater negotiating power for financial benefits, which yields higher salaries and stipends for residents. For example, in internal medicine residencies, unionized residency programs offer higher total compensation for residents than non-unionized programs. However, studies have shown that unionization made no difference in burnout, suicide rates, job satisfaction, duty-hour violations, mistreatment, or program educational environment. Moreover, unionization has in some cases had a negative impact on the faculty-resident relationship as well as decreased flexibility within the program. These mixed outcomes highlight the need for careful adaptation of union strategies for practicing surgeons.

The resident union movement provides a valuable foundation for the needs of orthopaedic surgeons, but there are a few key differences. Residents may prioritize better work hours or housing stipends, whereas surgeons’ challenges include malpractice insurance, compensation models, and pressures to provide more cost-efficient care. Nonetheless, the collective bargaining model remains applicable, allowing surgeons to implement similar organizing strategies, such as collective contract negotiations, while ensuring that a union’s priorities align with the unique economic reality of surgical practice.

Unionization may be relevant in today’s climate, where orthopaedic surgeons are navigating a system shaped by consolidation, productivity demands, and administrative control. Although it may not currently be a universal solution, it offers a clear mechanism to advocate for autonomy, sustainability, and care quality in surgical practice. Union efforts led by orthopaedic surgeons highlight that leadership within the specialty is already engaging with these challenges and shaping the path forward.

Aghdas Movassaghi, BS, is a fourth-year medical student at Michigan State University College of Human Medicine. Her research focuses on advancing equity in orthopaedic surgery through the study of gender bias in surgical literature, as well as improving clinical outcomes in shoulder arthroplasty.

Het Chavda, MS, is a third-year medical student at Texas A&M University College of Medicine. His research focuses primarily on patient-reported outcomes studies and quality improvement to optimize patient care.

Vani J. Sabesan, MD, FAAOS, is a board-certified orthopaedic surgeon and shoulder and elbow specialist at the Orthopedic Center of Palm Beach County in Florida. Dr. Sabesan has authored more than 105 peer-reviewed publications and holds leadership roles in national and international orthopaedic societies, with a focus on research, education, and diversity in the field.

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