March 18, 2026 • 28 mins
To help support sustainable surgical careers, the American College of Surgeons recently released a framework of workplace standards that can be customized by surgical discipline. This episode features Douglas E. Wood, MD, FACS, FRCSEd, Vice-Chair of the ACS Board of Regents, and Philip R. Wolinsky, MD, FACS, ACS Regent, discussing the standards, as well as new resources on surgeon unionization.
Talk about the podcast on social media using the hashtag #HouseofSurgery
- Douglas E. Wood, MD, FACS, FRCSEd, is the Henry N. Harkins Professor and Chair of the Department of Surgery at the University of Washington in Seattle
- Philip R. Wolinsky, MD, FACS, is the Division Chief of orthopaedic trauma and a professor of orthopaedics at Dartmouth University in Lebanon, New Hampshire
Copyright © 2026 by the American College of Surgeons (ACS). All rights reserved.
The contents of this podcast may be cited in academic publications but otherwise may not be reproduced, disseminated, or transmitted in any form by any means without the express written permission of ACS. These materials may not be resold nor used to create revenue-generating content by any entity other than the ACS without the express written permission of the ACS. The contents of these materials are strictly prohibited from being uploaded, shared, or incorporated in any third-party applications, platforms, software, or websites without prior written authorization from the ACS. This restriction explicitly includes, but is not limited to, the integration of ACS content into tools leveraging artificial intelligence (AI), machine learning, large language models, or generative AI technologies and infrastructures.
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Episode Transcript
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(00:03):
Welcome to the House of surgery,
a podcast brought to youby the American College of Surgeons.
In this series, you'll hear fromand about surgeons in all specialties,
in all practice configurations,and in all locations,
their success stories, advice, challengesthey've overcome,
and words of inspirationas they serve their patients with quality,
(00:26):
integrity and professionalismand strive to heal all with skill
and trust.
To help supportsustainable surgical careers,
The American College of Surgeonsrecently released a framework of workplace
standards that can be customizedby surgical discipline.
This episode features ACS leaders Drs.
(00:48):
Douglas Wood and Philip Wolinskydiscussing the standards,
as well as new resources on surgeonunionization.
The opinions
expressed in this podcastare those of the participants
and not necessarilythose of the American College of Surgeons.
Enjoy the program.
(01:12):
Hello, I'm Dr.
Douglas Ward.
I'm the chair of the Department of Surgeryat the University of Washington.
And I'm here with my colleague, Dr.
Phil Wolinsky.
Dr. Wolinksy, introduce yourself as well.
Thanks.
I'm an orthopedic trauma surgeon,
and I practice at Dartmouth Medical Centerin New Hampshire.
Well, Dr.
Wolinsky, I've had the privilegeof working with you in this new task force
(01:37):
developed from, in the American Collegeof Surgeons on unionization.
It was titled the Unionization Task Force.
And you were chosen to chair that task
force this past year.
Can you tell us a little bit about that?
What led to the creation of thattask force and what were the goals?
(01:59):
What was the intent behind this group?
Thanks for that intro.
And. Absolutely.
First, to be clear,
the goal of the unionization
part of this task force was to provideobjective data.
The College can never be a union,
and it can ever partner with a union.
(02:19):
But we felt that our members had a growinginterest in the topic of unionization.
We wanted to provide themwith information.
We felt there was a need to address thisbecause of the dissatisfaction
of the work environment, a lack of inputfor working conditions for our fellows.
We know there are very high ratesof burnout and moral injury.
(02:40):
Some articles citeas high as 60% of all physicians,
and maybe more so in younger physicianswho we definitely need to watch out for.
And we know that burnout has
a negative impact on patient careand physician well-being.
And at the same time, there has beena big shift in how we're employed.
Back in 2012, 60% of all practiceswere physicians own - physician owned.
(03:04):
And if we look at it now, about 78%of physicians are current employees
and they're eligible to be unionized.
So this seemed like a good time,to look into this.
I'm interested in that last statistic
that you just gaveabout physician employment.
Do you know anything about surgeonsspecifically?
(03:25):
Are surgeonseven more likely to be employed
than kind of the general communityof physicians or less likely?
That's quite a stark statistic
that you gave about the number of usthat are now
in employed situationsinstead of in a private practice.
(03:47):
I don't actually know the statisticsfor surgeons specifically.
The numbers that I've seen are physiciansin general,
and, seem to have accelerated during Covid.
Many physiciansjoined hospital based practices
because of financial challengesduring Covid.
You mentionedsome of the things that may be
(04:08):
consequences of us being now
employees rather than employers.
Yeah, how is that driving? Kind of,
how are
surgeons are feeling in termsof their autonomy
and their abilityto control their own environment?
(04:30):
Yeah.
I think, we all feelwe have less autonomy.
In additionto becoming hospital employees.
Hospital systems are becomingbigger and bigger
when they buy up different hospitals.
So it may not just be the hospitalthat you work at.
It could be
that your hospital system ownsmany other practices.
And with more employees,you have less and less of a say.
(04:54):
So documentation issues, resource issues,
asking to do more with less,
the ability to maybeif you don't like your work environment,
you can't just go across the streetbecause the place across the street
or the next town overmay be owned by the same hospital system.
So surgeons,
(05:14):
and physicians in general,think that they have less of a voice
in their everyday practice,and they might be scared to speak out
because of the lack of opportunitiesto go elsewhere.
Got it.
Yeah, I, I certainly hear that
from the physicians in my communityand from those in my own department.
And so, tell me a little bit about
(05:38):
what has developed in this unionizationtask force that you have chaired.
What are some of the key points that,
you learned about unionization?
And I think you saidsomething about this earlier,
but I'm going to askthe specific question.
Can the American College of Surgeonsbecome a union?
Yeah.
(05:58):
So I learned a lot about unionization.
I can't claim to be an expert.
I'll just cover some key points.
We all kick around this idea of a union,you know?
So what is a union?
It's basically an organizationthat's elected by a group of employees
to collectively bargainwith their employer.
And I'll talk about what collectivebargaining means in a few minutes.
(06:19):
And essentially,you can negotiate about a lot of things.
So this is just not about wages.
It's about hours and the waythat the federal law states it’s
other terms of the condition of employmentand no, it should be an air quotes.
You can't see me air quoting,but other terms and conditions
of employment can include thingslike benefits, the hours you work, work
(06:41):
rules, grievance procedures, documentationrequirements,
discharge policies, essentially,you know, anything,
that you could think of thatyou'd want to address in your workplace?
We don't really
know how many attending physiciansare in unions right now.
It's under 10%. The data is not robust.
We know the numbers are increasingfor residents considerably.
(07:04):
A lot of them have unionized.
There are, of course,upsides and downsides to unions.
The potential upsidesare that labor law offers
us, the employees,to have input into their workplace.
Now, I thought that our unionwould be like, say, the NFL union.
We would negotiate with our employersacross the entire country.
(07:28):
But that's not how it works.
Unions negotiate with employers.
They don't negotiatewith insurance companies.
So this is not a way to address issueswith CMS
or with insurance companiesfor reimbursement.
Unions don't do that.
The other thing is that due to legalstandards,
unions typically represent employeesat a single location.
(07:51):
Or if your hospital owns several locations
that are located close to each other,that will work, too.
But we're not talking about a nationwideor region-wide, organizations.
So those are some of the advantages.
There's disadvantages.
So it may limit your autonomy,you can't negotiate on your own.
You know, I don't know if your, surgeonscome to you, Dr.
(08:14):
Wood, and try and negotiatewith you independently.
But you would lose that.
You're now negotiating with pedswith general surgery with ortho
The other thing is, we're doing thisbecause we have a lot of bureaucracies,
and a union is another bureaucracy.
So are we just addingin another layer of bureaucracy?
Got it.
(08:35):
Yeah. Yeah.
And then independent physicianscan't unionize.
Employee physicians can unionize.
So are we going to change the workplaceenvironment
for different kinds of physiciansand generate tensions?
And then of course, there are dues.
And, you know, this raisesthe point of who can join a union so
residents can, they're not only learners,but they're employees.
(08:57):
And as far as attending physicians,
you cannot unionizeif you're an independent contractor
or if you're in private practiceor if you're tenure track or tenure
eligible,or if you supervise other employees
and supervision of nursesdoesn't count Okay.
But there are restrictions.
Wow. That's a lot of informationthat that you've come up with.
(09:22):
And I know there's more.
Let me come back to that big questionI asked you.
Could the American College of Surgeonsform a union for surgeons? So.
Absolutely not.
Okay, tell me more about that. Yeah.
I think this is a very important point,because
I thought it would be logicalfor the ACS to do this.
(09:43):
They are the House of Surgery,®they represent all surgeons -
who would be more logicalthan to form a union.
The problem is that there would be legaland operational issues.
So a tax exempt 501-C3 or 501-C6
has to focus on its primary activities,and it should be in capital letters.
This does not include union activities.
(10:05):
So using againair quotes significant resources
whatever that means for activitiesunrelated to a tax
exempt status could jeopardizethat tax exempt status.
So in order to be a union, surethe ACS could form a separate business.
But then you need all the resourcesand the experience in the unionization
(10:26):
arena, which is why people typicallyjoin already established unions.
I see.
Not only that,if we partnered with the union,
the IRS could look at that to seeif the ACS gave either free or discounted
resources to a union, andthat would not be looked upon favorably.
So short answer. No.
(10:46):
Okay. Yes.
Longer answer, still no. Yes, okay.
That's why I appreciate both the shortand long answer, because I got the no.
But it's helpful to understand
the substantial
legal limitationsthat there would be about the college,
leading an effort to form a union so
(11:08):
a union could be formed by someone else.
But this isn't somethingthat the American College of Surgeons
in its current formwould be able to be part of.
Correct.
And there are unions out therefor physicians, that you could join.
And if you're interested in finding outabout those, there's information now
about unionization on the ACS website
(11:30):
that has links to organizations like that.
Well,and you anticipated my next question.
That'sexactly what I was going to ask you.
I know that the work that your committeehas been doing
just got launched on the American Collegeof Surgeons website.
Just give us a, you know, what's there?
What's there as a resource for our fellowsand members?
(11:52):
Sure.
So it is live. It'sfairly easy to get there.
No one is going to remember an addressbut it's facs.org/unionization.
It's under the practicemanagement section of the website.
Or just go to ACS.
Make sure it'snot the American Chemical Society,
which always comes up firstand type union into the search bar.
And what our group worked onis there as well as other resources.
(12:15):
And as far as what's there,it's divided up by topic
and there are numerous topics,some of which we've been talking about,
but there are many moreand by career stage.
So by resident or by attending,
in addition to these frequentlyasked questions or informational items,
there is a bibliographyof some selected articles.
If you want to seewhere the information came from.
(12:37):
And like I said, links to organizationssuch as the National Labor Relations
Board, the AMA,or other medical organizations
that have delved into this areaand have commented on it,
and to existing physician unions.
Terrific.
I've looked through that,and it's a great resource.
These frequently asked questions,
(13:00):
the additional resources,
the bibliography, a rich resource of,I guess I call it,
you know, a place of truth
about union so that any of our members
that want to knowmore information, have that.
So thank you for doing that.
Now to move onto the part of the task force
(13:20):
that you headedup, on workplace standards.
As we looked into this, I think we morpheda little bit in our mission
and we looked at what tools couldwe develop that could help our fellows
and unionization or informationabout unionization is one tool.
And the second tool that you'reinstrumental in developing is workplace
(13:41):
standards.
Can you just comment on what those areand why you thought
that this would be helpful?
Yeah, I mean, this, the - as
we evaluatedall the components of unionization,
we recognized that there are a lot of,
positives and opportunity there and also
(14:02):
some barriers and some challenges,
both in the logisticsand also in the culture of our profession
and whether that was a way that we would,that we would best be served
in trying to regain some of the autonomythat we think is important
(14:24):
for the professionalismthat we have as surgeons.
And so, this evolved
into another componentthat we worked together in,
in the development of a frameworkfor workplace standards for surgeons.
And this connects to your earlier pointthat you said
at the beginning about, how
(14:48):
surgeons
have really a culture
of patients first and that professionalism
and that history of subjugating
our own priorities to the patientand in some ways to the system
to make sure we're caring for patients,has led to systems
(15:09):
counting on our endurance
to keep things getting done to beyond call
to cover increasing workloads of patients.
Yet we could not rely on
the unlimited endurance of surgeons
to fill in the gaps for healthcare for patients with surgical disease.
(15:32):
And so
trying to create some expectationsand boundaries around, things
like call scheduleor things like, census,
that
could give surgeons something to point to
as they are considering employment
in a given group or a given healthsystem seemed to be a different way
(15:55):
of approaching the similar aspect of,
trying to protect surgeons
from the unintentional or maybe
sometimes intentional exploitationof their work ethic
and their professionalism.
I like what you're saying.
It's almost like,correct me if I'm wrong, that
(16:16):
you're saying that hospitalshave an obligation to provide
physicians with the resourcesthey need to do their jobs,
and they can't just depend on usto continue just doing it,
perhaps at a considerable costto our personal lives.
Yeah, that's exactly right.
And and I think in general, everyone'swell intended.
(16:40):
And that's why I saymostly it's unintentional.
The potential demandon surgeons to outperform.
But I'mgoing to give a couple of examples.
So call schedules, the call schedules
that we all have, you know,different kinds of call schedule.
It's differentif you're an ophthalmologist,
(17:01):
then you're an orthopedic trauma surgeonlike yourself.
And it's different in multiple ways.
It's different by frequency and intensity.
Your call schedule as a transplant surgeon
has a completely different form
than your call scheduleas an endocrine surgeon.
And those need to be takeninto consideration in terms
(17:23):
of frequency and intensity.
And so part of this framework that we'vedeveloped is to try to, at least
put some expectations of, what would be,
kind of reasonable types of callthat people could do
and then what would be
evidence of excessive calland excessive call
(17:45):
that should have additional compensationto support it.
Because there might bereasons, because somebody is
out, or
the practice is short for a period of timethat there is excessive call,
but then there ought to be some resourcesto compensate for that as well.
So that's one example, a second examplethat is near and dear
(18:09):
to all of our hearts as surgeons is accessto the operating room.
Glad to hear you say that.
So, you know, part of these workplacestandards
try to define, you know,what would be reasonable expectations
for a full time surgeon in termsof how much block time they should have.
And of course, that also maybe highly variable.
(18:30):
We've suggested a relatively simpleformula of
those that have work RVU
productivity expectations as part of their
employment or their compensation.
It's relatively easy on an annual basisto calculate
(18:50):
work RVU’sper OR block for a given practitioner,
which might be very differentfor a vascular surgeon
than it is for a surgical oncologist
or a orthopedic surgeon doing spine,
which is but one at the individual level,because based on one's practice,
(19:11):
could say I on average producesthis many work RVUs
per OR block, and therefore
I need enough OR blocksto meet the expectations
that my health systemor my department, my group, has for me.
That seems like a pretty reasonable thing
that supports both the surgeon
(19:34):
and the health systemthat is employing them
to have better alignment of,
you know, whatthe expectations are for productivity
and what the resources are to allowthat expectation to be fulfilled.
Its great, you’re smiling at mewhen you say this and I'm smiling at you.
This seems so logical and -But how any discussions?
(19:54):
I mean, I have this discussionevery year of my career.
Phil you're not doing enough RVUs.
Well, the OR’s inefficient.
Or, I don't
have enough access to the operating room,so this sounds perfectly logical
and it's almost astounding
that we would have to say this,but I think it's very helpful.
But let me follow thatwith another question.
Yeah.
(20:14):
I'm an orthopedic traumasurgeon, you’re not.
Our workflows are very, very different.
So how would this process accountfor the different kinds of surgeons?
Optho is different. Ortho is different.
Total joints are different.
Vascular is different.
Or are we just coming up with one
generalized documentthat's applicable to everyone?
(20:37):
Great question.
Thanks for asking it. Because
what we developed
at the American College of Surgeonsis what I've labeled as a framework,
which is purposefully generic
and is not specialty specificand is not meant to be
the document that is applied for you
(20:58):
as an orthopedic trauma surgeonor me as a cardiothoracic surgeon.
A very important part of thisis that this framework is
then meant to be usedby different specialties
to develop a specialty
specific set of recommendations
that would be specificfor orthopedic trauma,
(21:19):
that would be specificfor cardiac surgeons or thoracic
surgeons, or surgical oncologists,or vascular surgeons.
And what we are working on right now
is partneringwith multiple surgical specialties,
giving them this framework to work with
and then allowing them to work
(21:40):
within the expertiseof their specialty society
to take that frameworkand make it effective for their specialty,
with the intent
that this would be publishedin their specialty journal.
The framework document
is published in the Journalof the American College of Surgeons,
(22:01):
and I encourage people to go to see that
and see what has been published in JACS.
But our intent is thatthis would then be rolled out specialty
by specialty in a way that is applicableand nuanced and appropriate
for an ophthalmologistor an orthopedic spine surgeon.
(22:23):
Yeah, I think that's great.
I know the Orthopaedic Trauma Associationis signed on to this and - Yeah.
This is a great example
of the American College of Surgeons,I think, as the House of Surgery.®
While allowing each individualtype of surgeon the freedom to develop
the resourcesthat they have the expertise to do that.
(22:44):
Well,and I'll just, you know, you just said
how this
how this works with specialty societiesand the House of Surgery®
from representingthe American College of Surgeons.
This is really,I think, a great opportunity
for specialty societies to do something
(23:06):
that benefits their constituency,the surgeons that are the members
and demonstrating value
to the members of their specialty society,
and in so doing,empowering those individuals to have
something that helps themas they negotiate for their job
(23:30):
and their contract
and helps the specialty societydemonstrate value
to the, their constituency.
And then I think it's a value
to the American College of Surgeonsbeing able to be the convener
that helps support the specialty societiesand our fellows and members nationally.
(23:51):
And I’m even going to add,
I think this is a benefitfor health systems as well,
for what we just talked about a minute agoof helping health systems
know what they need to do
to recruit and retainand have resources aligned
with what surgeons need to be effective.
(24:14):
Yeah,I think those are some excellent points.
We are stronger together.
I think one of the reasons perhaps
our lives have gotten to where they areis, we've been fragmented
and we need to come together in thisarena and work together.
It's not orthopedic surgeonagainst cardiac surgeon, or neurosurgeon
(24:34):
who gets that OR.
We all need to havethe adequate resources,
and we're only going to get thoseif we work together.
Great point.
And also,you answered my cynical New Yorker
question, which was going to bewe can write all these things,
and perhaps our bosses are going tocome to us and say, so what?
You put this out,
(24:56):
why should I pay attention to this?
And you answer that
very eloquently about the benefit of thisto the health systems;
when you're seeking to hire surgeons,keep their surgeons
- whom they need in order to providehealth care.
Exactly.
I think that's a that's a key aspectthat I think can get lost in this.
This can feel like an us versus them.
(25:18):
I don't really see it that way.
I see that this is a win-win.
It's a win for individual surgeons.
It's a win for our specialty societies
and for the College, who are
here to represent our surgeonsand try to create an environment
where we support our surgeonsto care for the surgical patients.
(25:39):
But as we just discussed,I also think it's a it's a win
for the health systems that we are workingwith to better understand
how they can supportthe surgical care in their health system.
I agree with you.
Well, Dr.
Wolinsky, I just, you know,I want to take a minute to thank you.
(26:01):
You really have led this whole,
what started as a unionizationtask force.
We have changed the name of that nowas we've,
that task force is now the OptimalWorking Enviornment for Surgeon.
And, you know, this developmentof the extensive
informationthat you've developed about unionization
(26:22):
is really importantfor our fellows and members.
And we're enthusiasticabout the development
of multiple specialty specific workplacestandards, because they can provide value
and empowerment to surgeons and helpcreate sustainable surgical careers.
As you just said,
this is a great exampleof how the American College of Surgeons,
(26:46):
as the House of Surgery® is convening
and supporting our specialty organizations
and the diverse constituencyof the surgeons that we represent.
So, you know, you have been a leaderin this whole effort.
And I, mythanks to you and the other members
of this task forcethat we've been working on together.
(27:08):
Well, thank you for that praise.
I want to make it very clear,this is not just me.
My name may have beenat the top of this, but,
we had a big groupthat worked on this collaboratively.
You took on the workplace standardsand reaching out to other societies.
And also Dr.
Patricia Turner for putting the resourcesof the ACS behind this.
(27:31):
And this is very mucha collaborative effort.
And, you know,this fits really well under the umbrella
of the House of Surgery®as a role for the ACS.
Standing up for all surgeonsand representing all kinds of surgeons.
Terrific. Well, thank you, Dr. Wolinsky.
Thank you, Dr. Wood.
(27:55):
Thank youfor joining us on the House of Surgery®
podcast, brought to youby the American College of Surgeons.
If you like this podcast,please rate it five stars
and let your friends and colleaguesknow about the podcast.
On social media,use the hashtag #HouseofSurgery.
You can learn moreabout the American College of Surgeons,
its members, programs,products, and services at facs.org.
Welcome to the House of surgery,
a podcast brought to youby the American College of Surgeons.
In this series, you'll hear fromand about surgeons in all specialties,
in all practice configurations,and in all locations,
their success stories, advice, challengesthey've overcome,
and words of inspirationas they serve their patients with quality,
(00:26):
integrity and professionalismand strive to heal all with skill
and trust.
To help supportsustainable surgical careers,
The American College of Surgeonsrecently released a framework of workplace
standards that can be customizedby surgical discipline.
This episode features ACS leaders Drs.
(00:48):
Douglas Wood and Philip Wolinskydiscussing the standards,
as well as new resources on surgeonunionization.
The opinions
expressed in this podcastare those of the participants
and not necessarilythose of the American College of Surgeons.
Enjoy the program.
(01:12):
Hello, I'm Dr.
Douglas Ward.
I'm the chair of the Department of Surgeryat the University of Washington.
And I'm here with my colleague, Dr.
Phil Wolinsky.
Dr. Wolinksy, introduce yourself as well.
Thanks.
I'm an orthopedic trauma surgeon,
and I practice at Dartmouth Medical Centerin New Hampshire.
Well, Dr.
Wolinsky, I've had the privilegeof working with you in this new task force
(01:37):
developed from, in the American Collegeof Surgeons on unionization.
It was titled the Unionization Task Force.
And you were chosen to chair that task
force this past year.
Can you tell us a little bit about that?
What led to the creation of thattask force and what were the goals?
(01:59):
What was the intent behind this group?
Thanks for that intro.
And. Absolutely.
First, to be clear,
the goal of the unionization
part of this task force was to provideobjective data.
The College can never be a union,
and it can ever partner with a union.
(02:19):
But we felt that our members had a growinginterest in the topic of unionization.
We wanted to provide themwith information.
We felt there was a need to address thisbecause of the dissatisfaction
of the work environment, a lack of inputfor working conditions for our fellows.
We know there are very high ratesof burnout and moral injury.
(02:40):
Some articles citeas high as 60% of all physicians,
and maybe more so in younger physicianswho we definitely need to watch out for.
And we know that burnout has
a negative impact on patient careand physician well-being.
And at the same time, there has beena big shift in how we're employed.
Back in 2012, 60% of all practiceswere physicians own - physician owned.
(03:04):
And if we look at it now, about 78%of physicians are current employees
and they're eligible to be unionized.
So this seemed like a good time,to look into this.
I'm interested in that last statistic
that you just gaveabout physician employment.
Do you know anything about surgeonsspecifically?
(03:25):
Are surgeonseven more likely to be employed
than kind of the general communityof physicians or less likely?
That's quite a stark statistic
that you gave about the number of usthat are now
in employed situationsinstead of in a private practice.
(03:47):
I don't actually know the statisticsfor surgeons specifically.
The numbers that I've seen are physiciansin general,
and, seem to have accelerated during Covid.
Many physiciansjoined hospital based practices
because of financial challengesduring Covid.
You mentionedsome of the things that may be
(04:08):
consequences of us being now
employees rather than employers.
Yeah, how is that driving? Kind of,
how are
surgeons are feeling in termsof their autonomy
and their abilityto control their own environment?
(04:30):
Yeah.
I think, we all feelwe have less autonomy.
In additionto becoming hospital employees.
Hospital systems are becomingbigger and bigger
when they buy up different hospitals.
So it may not just be the hospitalthat you work at.
It could be
that your hospital system ownsmany other practices.
And with more employees,you have less and less of a say.
(04:54):
So documentation issues, resource issues,
asking to do more with less,
the ability to maybeif you don't like your work environment,
you can't just go across the streetbecause the place across the street
or the next town overmay be owned by the same hospital system.
So surgeons,
(05:14):
and physicians in general,think that they have less of a voice
in their everyday practice,and they might be scared to speak out
because of the lack of opportunitiesto go elsewhere.
Got it.
Yeah, I, I certainly hear that
from the physicians in my communityand from those in my own department.
And so, tell me a little bit about
(05:38):
what has developed in this unionizationtask force that you have chaired.
What are some of the key points that,
you learned about unionization?
And I think you saidsomething about this earlier,
but I'm going to askthe specific question.
Can the American College of Surgeonsbecome a union?
Yeah.
(05:58):
So I learned a lot about unionization.
I can't claim to be an expert.
I'll just cover some key points.
We all kick around this idea of a union,you know?
So what is a union?
It's basically an organizationthat's elected by a group of employees
to collectively bargainwith their employer.
And I'll talk about what collectivebargaining means in a few minutes.
(06:19):
And essentially,you can negotiate about a lot of things.
So this is just not about wages.
It's about hours and the waythat the federal law states it’s
other terms of the condition of employmentand no, it should be an air quotes.
You can't see me air quoting,but other terms and conditions
of employment can include thingslike benefits, the hours you work, work
(06:41):
rules, grievance procedures, documentationrequirements,
discharge policies, essentially,you know, anything,
that you could think of thatyou'd want to address in your workplace?
We don't really
know how many attending physiciansare in unions right now.
It's under 10%. The data is not robust.
We know the numbers are increasingfor residents considerably.
(07:04):
A lot of them have unionized.
There are, of course,upsides and downsides to unions.
The potential upsidesare that labor law offers
us, the employees,to have input into their workplace.
Now, I thought that our unionwould be like, say, the NFL union.
We would negotiate with our employersacross the entire country.
(07:28):
But that's not how it works.
Unions negotiate with employers.
They don't negotiatewith insurance companies.
So this is not a way to address issueswith CMS
or with insurance companiesfor reimbursement.
Unions don't do that.
The other thing is that due to legalstandards,
unions typically represent employeesat a single location.
(07:51):
Or if your hospital owns several locations
that are located close to each other,that will work, too.
But we're not talking about a nationwideor region-wide, organizations.
So those are some of the advantages.
There's disadvantages.
So it may limit your autonomy,you can't negotiate on your own.
You know, I don't know if your, surgeonscome to you, Dr.
(08:14):
Wood, and try and negotiatewith you independently.
But you would lose that.
You're now negotiating with pedswith general surgery with ortho
The other thing is, we're doing thisbecause we have a lot of bureaucracies,
and a union is another bureaucracy.
So are we just addingin another layer of bureaucracy?
Got it.
(08:35):
Yeah. Yeah.
And then independent physicianscan't unionize.
Employee physicians can unionize.
So are we going to change the workplaceenvironment
for different kinds of physiciansand generate tensions?
And then of course, there are dues.
And, you know, this raisesthe point of who can join a union so
residents can, they're not only learners,but they're employees.
(08:57):
And as far as attending physicians,
you cannot unionizeif you're an independent contractor
or if you're in private practiceor if you're tenure track or tenure
eligible,or if you supervise other employees
and supervision of nursesdoesn't count Okay.
But there are restrictions.
Wow. That's a lot of informationthat that you've come up with.
(09:22):
And I know there's more.
Let me come back to that big questionI asked you.
Could the American College of Surgeonsform a union for surgeons? So.
Absolutely not.
Okay, tell me more about that. Yeah.
I think this is a very important point,because
I thought it would be logicalfor the ACS to do this.
(09:43):
They are the House of Surgery,®they represent all surgeons -
who would be more logicalthan to form a union.
The problem is that there would be legaland operational issues.
So a tax exempt 501-C3 or 501-C6
has to focus on its primary activities,and it should be in capital letters.
This does not include union activities.
(10:05):
So using againair quotes significant resources
whatever that means for activitiesunrelated to a tax
exempt status could jeopardizethat tax exempt status.
So in order to be a union, surethe ACS could form a separate business.
But then you need all the resourcesand the experience in the unionization
(10:26):
arena, which is why people typicallyjoin already established unions.
I see.
Not only that,if we partnered with the union,
the IRS could look at that to seeif the ACS gave either free or discounted
resources to a union, andthat would not be looked upon favorably.
So short answer. No.
(10:46):
Okay. Yes.
Longer answer, still no. Yes, okay.
That's why I appreciate both the shortand long answer, because I got the no.
But it's helpful to understand
the substantial
legal limitationsthat there would be about the college,
leading an effort to form a union so
(11:08):
a union could be formed by someone else.
But this isn't somethingthat the American College of Surgeons
in its current formwould be able to be part of.
Correct.
And there are unions out therefor physicians, that you could join.
And if you're interested in finding outabout those, there's information now
about unionization on the ACS website
(11:30):
that has links to organizations like that.
Well,and you anticipated my next question.
That'sexactly what I was going to ask you.
I know that the work that your committeehas been doing
just got launched on the American Collegeof Surgeons website.
Just give us a, you know, what's there?
What's there as a resource for our fellowsand members?
(11:52):
Sure.
So it is live. It'sfairly easy to get there.
No one is going to remember an addressbut it's facs.org/unionization.
It's under the practicemanagement section of the website.
Or just go to ACS.
Make sure it'snot the American Chemical Society,
which always comes up firstand type union into the search bar.
And what our group worked onis there as well as other resources.
(12:15):
And as far as what's there,it's divided up by topic
and there are numerous topics,some of which we've been talking about,
but there are many moreand by career stage.
So by resident or by attending,
in addition to these frequentlyasked questions or informational items,
there is a bibliographyof some selected articles.
If you want to seewhere the information came from.
(12:37):
And like I said, links to organizationssuch as the National Labor Relations
Board, the AMA,or other medical organizations
that have delved into this areaand have commented on it,
and to existing physician unions.
Terrific.
I've looked through that,and it's a great resource.
These frequently asked questions,
(13:00):
the additional resources,
the bibliography, a rich resource of,I guess I call it,
you know, a place of truth
about union so that any of our members
that want to knowmore information, have that.
So thank you for doing that.
Now to move onto the part of the task force
(13:20):
that you headedup, on workplace standards.
As we looked into this, I think we morpheda little bit in our mission
and we looked at what tools couldwe develop that could help our fellows
and unionization or informationabout unionization is one tool.
And the second tool that you'reinstrumental in developing is workplace
(13:41):
standards.
Can you just comment on what those areand why you thought
that this would be helpful?
Yeah, I mean, this, the - as
we evaluatedall the components of unionization,
we recognized that there are a lot of,
positives and opportunity there and also
(14:02):
some barriers and some challenges,
both in the logisticsand also in the culture of our profession
and whether that was a way that we would,that we would best be served
in trying to regain some of the autonomythat we think is important
(14:24):
for the professionalismthat we have as surgeons.
And so, this evolved
into another componentthat we worked together in,
in the development of a frameworkfor workplace standards for surgeons.
And this connects to your earlier pointthat you said
at the beginning about, how
(14:48):
surgeons
have really a culture
of patients first and that professionalism
and that history of subjugating
our own priorities to the patientand in some ways to the system
to make sure we're caring for patients,has led to systems
(15:09):
counting on our endurance
to keep things getting done to beyond call
to cover increasing workloads of patients.
Yet we could not rely on
the unlimited endurance of surgeons
to fill in the gaps for healthcare for patients with surgical disease.
(15:32):
And so
trying to create some expectationsand boundaries around, things
like call scheduleor things like, census,
that
could give surgeons something to point to
as they are considering employment
in a given group or a given healthsystem seemed to be a different way
(15:55):
of approaching the similar aspect of,
trying to protect surgeons
from the unintentional or maybe
sometimes intentional exploitationof their work ethic
and their professionalism.
I like what you're saying.
It's almost like,correct me if I'm wrong, that
(16:16):
you're saying that hospitalshave an obligation to provide
physicians with the resourcesthey need to do their jobs,
and they can't just depend on usto continue just doing it,
perhaps at a considerable costto our personal lives.
Yeah, that's exactly right.
And and I think in general, everyone'swell intended.
(16:40):
And that's why I saymostly it's unintentional.
The potential demandon surgeons to outperform.
But I'mgoing to give a couple of examples.
So call schedules, the call schedules
that we all have, you know,different kinds of call schedule.
It's differentif you're an ophthalmologist,
(17:01):
then you're an orthopedic trauma surgeonlike yourself.
And it's different in multiple ways.
It's different by frequency and intensity.
Your call schedule as a transplant surgeon
has a completely different form
than your call scheduleas an endocrine surgeon.
And those need to be takeninto consideration in terms
(17:23):
of frequency and intensity.
And so part of this framework that we'vedeveloped is to try to, at least
put some expectations of, what would be,
kind of reasonable types of callthat people could do
and then what would be
evidence of excessive calland excessive call
(17:45):
that should have additional compensationto support it.
Because there might bereasons, because somebody is
out, or
the practice is short for a period of timethat there is excessive call,
but then there ought to be some resourcesto compensate for that as well.
So that's one example, a second examplethat is near and dear
(18:09):
to all of our hearts as surgeons is accessto the operating room.
Glad to hear you say that.
So, you know, part of these workplacestandards
try to define, you know,what would be reasonable expectations
for a full time surgeon in termsof how much block time they should have.
And of course, that also maybe highly variable.
(18:30):
We've suggested a relatively simpleformula of
those that have work RVU
productivity expectations as part of their
employment or their compensation.
It's relatively easy on an annual basisto calculate
(18:50):
work RVU’sper OR block for a given practitioner,
which might be very differentfor a vascular surgeon
than it is for a surgical oncologist
or a orthopedic surgeon doing spine,
which is but one at the individual level,because based on one's practice,
(19:11):
could say I on average producesthis many work RVUs
per OR block, and therefore
I need enough OR blocksto meet the expectations
that my health systemor my department, my group, has for me.
That seems like a pretty reasonable thing
that supports both the surgeon
(19:34):
and the health systemthat is employing them
to have better alignment of,
you know, whatthe expectations are for productivity
and what the resources are to allowthat expectation to be fulfilled.
Its great, you’re smiling at mewhen you say this and I'm smiling at you.
This seems so logical and -But how any discussions?
(19:54):
I mean, I have this discussionevery year of my career.
Phil you're not doing enough RVUs.
Well, the OR’s inefficient.
Or, I don't
have enough access to the operating room,so this sounds perfectly logical
and it's almost astounding
that we would have to say this,but I think it's very helpful.
But let me follow thatwith another question.
Yeah.
(20:14):
I'm an orthopedic traumasurgeon, you’re not.
Our workflows are very, very different.
So how would this process accountfor the different kinds of surgeons?
Optho is different. Ortho is different.
Total joints are different.
Vascular is different.
Or are we just coming up with one
generalized documentthat's applicable to everyone?
(20:37):
Great question.
Thanks for asking it. Because
what we developed
at the American College of Surgeonsis what I've labeled as a framework,
which is purposefully generic
and is not specialty specificand is not meant to be
the document that is applied for you
(20:58):
as an orthopedic trauma surgeonor me as a cardiothoracic surgeon.
A very important part of thisis that this framework is
then meant to be usedby different specialties
to develop a specialty
specific set of recommendations
that would be specificfor orthopedic trauma,
(21:19):
that would be specificfor cardiac surgeons or thoracic
surgeons, or surgical oncologists,or vascular surgeons.
And what we are working on right now
is partneringwith multiple surgical specialties,
giving them this framework to work with
and then allowing them to work
(21:40):
within the expertiseof their specialty society
to take that frameworkand make it effective for their specialty,
with the intent
that this would be publishedin their specialty journal.
The framework document
is published in the Journalof the American College of Surgeons,
(22:01):
and I encourage people to go to see that
and see what has been published in JACS.
But our intent is thatthis would then be rolled out specialty
by specialty in a way that is applicableand nuanced and appropriate
for an ophthalmologistor an orthopedic spine surgeon.
(22:23):
Yeah, I think that's great.
I know the Orthopaedic Trauma Associationis signed on to this and - Yeah.
This is a great example
of the American College of Surgeons,I think, as the House of Surgery.®
While allowing each individualtype of surgeon the freedom to develop
the resourcesthat they have the expertise to do that.
(22:44):
Well,and I'll just, you know, you just said
how this
how this works with specialty societiesand the House of Surgery®
from representingthe American College of Surgeons.
This is really,I think, a great opportunity
for specialty societies to do something
(23:06):
that benefits their constituency,the surgeons that are the members
and demonstrating value
to the members of their specialty society,
and in so doing,empowering those individuals to have
something that helps themas they negotiate for their job
(23:30):
and their contract
and helps the specialty societydemonstrate value
to the, their constituency.
And then I think it's a value
to the American College of Surgeonsbeing able to be the convener
that helps support the specialty societiesand our fellows and members nationally.
(23:51):
And I’m even going to add,
I think this is a benefitfor health systems as well,
for what we just talked about a minute agoof helping health systems
know what they need to do
to recruit and retainand have resources aligned
with what surgeons need to be effective.
(24:14):
Yeah,I think those are some excellent points.
We are stronger together.
I think one of the reasons perhaps
our lives have gotten to where they areis, we've been fragmented
and we need to come together in thisarena and work together.
It's not orthopedic surgeonagainst cardiac surgeon, or neurosurgeon
(24:34):
who gets that OR.
We all need to havethe adequate resources,
and we're only going to get thoseif we work together.
Great point.
And also,you answered my cynical New Yorker
question, which was going to bewe can write all these things,
and perhaps our bosses are going tocome to us and say, so what?
You put this out,
(24:56):
why should I pay attention to this?
And you answer that
very eloquently about the benefit of thisto the health systems;
when you're seeking to hire surgeons,keep their surgeons
- whom they need in order to providehealth care.
Exactly.
I think that's a that's a key aspectthat I think can get lost in this.
This can feel like an us versus them.
(25:18):
I don't really see it that way.
I see that this is a win-win.
It's a win for individual surgeons.
It's a win for our specialty societies
and for the College, who are
here to represent our surgeonsand try to create an environment
where we support our surgeonsto care for the surgical patients.
(25:39):
But as we just discussed,I also think it's a it's a win
for the health systems that we are workingwith to better understand
how they can supportthe surgical care in their health system.
I agree with you.
Well, Dr.
Wolinsky, I just, you know,I want to take a minute to thank you.
(26:01):
You really have led this whole,
what started as a unionizationtask force.
We have changed the name of that nowas we've,
that task force is now the OptimalWorking Enviornment for Surgeon.
And, you know, this developmentof the extensive
informationthat you've developed about unionization
(26:22):
is really importantfor our fellows and members.
And we're enthusiasticabout the development
of multiple specialty specific workplacestandards, because they can provide value
and empowerment to surgeons and helpcreate sustainable surgical careers.
As you just said,
this is a great exampleof how the American College of Surgeons,
(26:46):
as the House of Surgery® is convening
and supporting our specialty organizations
and the diverse constituencyof the surgeons that we represent.
So, you know, you have been a leaderin this whole effort.
And I, mythanks to you and the other members
of this task forcethat we've been working on together.
(27:08):
Well, thank you for that praise.
I want to make it very clear,this is not just me.
My name may have beenat the top of this, but,
we had a big groupthat worked on this collaboratively.
You took on the workplace standardsand reaching out to other societies.
And also Dr.
Patricia Turner for putting the resourcesof the ACS behind this.
(27:31):
And this is very mucha collaborative effort.
And, you know,this fits really well under the umbrella
of the House of Surgery®as a role for the ACS.
Standing up for all surgeonsand representing all kinds of surgeons.
Terrific. Well, thank you, Dr. Wolinsky.
Thank you, Dr. Wood.
(27:55):
Thank youfor joining us on the House of Surgery®
podcast, brought to youby the American College of Surgeons.
If you like this podcast,please rate it five stars
and let your friends and colleaguesknow about the podcast.
On social media,use the hashtag #HouseofSurgery.
You can learn moreabout the American College of Surgeons,
its members, programs,products, and services at facs.org.
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