Primary care physicians at the Boston-based health system have voted overwhelmingly to join a national union.

One of the organizers of a primary care physician union at Mass General Brigham (MGB) is hailing the recent vote to form the union as a resounding success.

PCPs at MGB have been seeking to form a union for a year. MGB challenged the unionization effort at the National Labor Relations Board (NLRB) on the basis that many of the doctors did not belong in the same bargaining unit. The NLRB rejected MGB's challenge in April, but the health system is continuing to push the point with the federal agency.

On May 30, the PCPs voted 183-26 to join Doctors Council SEIU, the country’s oldest and largest union of attending physicians.

Michael Barnett, MD, a primary care physician at Brigham and Women's Advanced Primary Care Associates and a member of the PCP union's organizing committee, says the vote represents overwhelming support for the union.

"We had 209 ballots submitted for 237 eligible PCPs. So, our turnout was 88%," Barnett says. "The turnout was high, and those who voted support what we are doing."

MGB commented on the union vote in a prepared statement.

"Mass General Brigham respects the rights of employees to organize under the National Labor Relations Act, and we are committed to ensuring that any such process complies with applicable labor law," the statement says. "Prior to this vote, we formally requested the National Labor Relations Board to review whether the composition of the proposed bargaining unit is appropriate under the law for acute care hospitals, and we await their decision."

The prepared statement says the health system is committed to providing primary care services.

"We deeply value our physicians and have been working since fall of 2023 to improve the primary care experience based on direct physician feedback," the statement says. "Our ongoing investment in primary care reflects this long-term commitment to improving the experience of both our physicians and the patients they serve."

Michael Barnett, MD, is a primary care physician at Brigham and Women's Advanced Primary Care Associates. Photo courtesy of Michael Barnett.

Why PCPs want to have a union

There are several reasons why most PCPs at MGB support forming a union, according to Barnett.

"Most importantly, we want to make sure that primary care has a seat at the table for leadership decisions," Barnett says. "Part of what has led us to this point is a feeling of disempowerment and an inability to have a say in how investments or lack of investments in primary care are directed."

Barnett cited many other reasons for PCP support of the unionization effort.

• Concern over understaffing and high staff turnover
   
• A belief that PCP patient panel sizes are unrealistic
   
• A desire to align benefits and compensation with national standards, particularly given the high cost of living in the Boston area
   
• MGB has cut benefits for employees who work less than half time, which disproportionately affects PCPs
   
• The absence of a structured system for PCP coverage when doctors go on leave such as parental leave, which requires the remaining doctors to pick up more patient visits without a corresponding increase in compensation
   
• MGB has discontinued services that helped support primary care practices and their patients such as programs that helped patients manage their blood pressure and cholesterol remotely as well as a smoking cessation program

The PCPs are also wary of a pledge from MGB to invest $400 million in primary care, Barnett explains.

"MGB has made this unforced pledge of putting $400 million into primary care over the next five years," Barnett says. "We want to have input into how that money is spent, and we want to hold MGB accountable for making sure the health system is spending money in ways that improve the lives of our physicians and patients as well as improve our clinics."

State of labor relations among the PCPs

PCPs are discouraged that MGB has shown resistance to their unionization effort, according to Barnett.

"It is particularly disappointing now that we have had an election, and we have a resounding mandate, with nearly nine of 10 of our colleagues supporting the union," Barnett says. "MGB is still sticking to the narrative that they need to define our bargaining unit legally, which is taking advantage of an anachronistic technicality."

Many MGB physicians feel that the health system's leadership is moving in the wrong direction, Barnett explains.

"PCPs as well as many other doctors in the health system are skeptical that we are moving in a direction that is in the best interest of patients or doctors in the health system," Barnett says. "They have lost our trust. Because they are not responding to us and they have lost our trust, we need to demand a seat at the table and have more control over what happens."

A robust command center has helped Carilion Clinic manage its stretched hospital bed capacity.

Carilion Clinic has mastered the intricacies of operating a command center that manages patient transfers into and out of the health system.

Like many health systems across the country, Carilion Clinic is grappling with patient volumes that stretch bed capacity. Under these circumstances, managing patient flow and patient transfers into and out of the health system are crucial.

"We have real-time assessment of every hospital bed in the health system, including emergency departments," says Paul Haskins, MD, SVP medical director of the Carilion Transfer and Operations Center. "So when you have an enterprise command center, it has all aspects of patient flow, including a real-time situational awareness of the primary drivers of hospital systems, which include the transfer process into the system, the operating rooms, and the emergency departments."

Click here to view the accompanying HealthLeaders story.

A month-long rotation program gives residents experience in what it is like to live and work in a rural community.

Sanford Health and Hennepin Healthcare have established a rural rotation program to encourage medical residents to practice in rural communities.

About 20% of the U.S. population lives in rural areas but only 9% of the country's physicians practice in rural communities, according to the Bureau of Health Professions. A study published in Annals of Emergency Medicine found that 92% of emergency physicians practice in urban areas.

Minneapolis-based Hennepin Healthcare, which includes a 484-bed academic medical center, is sending emergency medicine and psychiatry residents on a month-long rotation to Sanford Health Bemidji in northern Minnesota. Sanford Health Bemidji includes Sanford Bemidji Medical Center.

Bemidji, Minnesota, has a population of nearly 16,000 and is surrounded by rural communities.

The rural rotation is designed to give residents experience in living and working in a rural setting.

"Most residents do not know what it is like to practice medicine in a rural hospital," says Daniel Hoody, MD, CMO of Sanford Health Bemidji. "In addition, if residents practice in an urban area, they are not well-equipped to understand what it is like to send a patient from a rural area into an urban center."

Unlike other rural residency programs across the county, where residents drive from an urban center to a rural hospital then drive home at night, the Bemidji program provides residents with an immersive experience. The program provides housing for residents in a welcoming environment, according to Meghan Walsh, MD, MPH, chief academic officer at Hennepin Healthcare.

"Residents go to and from the hospital every day, then at the end of the month, the residents return to their regular programming in Minneapolis," Walsh says. "We are already seeing that one month of a lived-in experience is leading to an interest in practicing in Bemidji and other rural communities."

The program separates the myths and truths about physicians living and working in a rural community.

"It is more exciting for the residents than they might have anticipated," Hoody says. "There are things going on in town, and we try to get the residents engaged in some of the things people experience if they live in town their whole lives."

The program shows residents that there is a good quality of life in a rural community. Hoody believes that it's easy to achieve work-life balance when you are not tethered to traffic or other discomforts of a big city.

"I like to tell recruits that you can do two things after work rather than one in Bemidji," Hoody says. "You can ski for an hour or two, go home and shower, then still have time to go out for dinner with friends. That is often not tenable in a major metropolitan area."

Daniel Hoody, MD, is CMO of Sanford Health Bemidji. Photo courtesy of Sanford Health.

Exposure to rural medicine

The Bemidji program gives residents exposure to the practice of medicine in rural areas and dispels misconceptions about what it is like to practice in a rural community.

In Bemidji, residents learn how to practice medicine with limited resources compared to practicing in an urban center, according to Walsh.

"If a patient falls and hits their head, they can have a brain bleed. In our Level 1 trauma center, literally within 10 minutes at the bedside, you can have a neurologist, a neurosurgeon, a trauma surgeon, an internist, and a critical care team for the patient," Walsh says. "At Bemidji, it is different. You do not have every single Level 1 trauma center resource at your fingertips within 10 minutes."

Many residents assume that they will be treating low acuity patients in a rural setting, but the Bemidji program shows them that rural medicine can be a challenging experience, Walsh explains.

"Residents have been ending their month-long rotation with an appreciation for the complexity, acuity, and challenge of treating patients at Sanford," Walsh says. "They feel their Level 1 trauma center skills were taken to the edge of their comfort zone, with supervision and appropriate support."

The Bemidji program residents learn how to treat patients safely in a rural setting as well as the value of treating patients close to home rather than transferring them to larger medical facilities, according to Hoody.

"The residents bring the latest and greatest care from an academic medical center to Bemidji, and they learn from the decades of experience on the ground at Bemidji to take care of patients when you have limited resources," Hoody says.

When it comes to acute care, the decision to transfer patients from Bemidji to a larger medical facility is not taken lightly, Hoody explains.

"It's a huge deal if we have to transfer a patient to Fargo," Hoody says. "The whole family must go over and stay at a hotel. They must take days off from work. It's better if we can keep patients here in Bemidji."

Bolstering Sanford Health Bemidji's staff

Hoody hopes the rotation program will help fill a need at Sanford Health Bemidji.

"Emergency medicine and psychiatry are areas of recruiting need," Hoody says. "For both emergency medicine and psychiatry, we are not fully staffed with employed clinicians, so this program is a nice adjunct to other recruiting efforts by exposing residents to rural medicine."

The partnership with Hennepin Healthcare gives Sanford Health Bemidji a capability that would be hard to achieve on its own. According to Walsh, the model is leveraging the strengths of an urban teaching hospital and a rural community that does not have the infrastructure, resources, and personnel to build their own teaching hospital.

"There is data to show that as few as one or two months of a rural experience for residents is enough to create interest in practicing in a rural setting," Walsh says. "We are testing this hypothesis."

The rural rotation program is giving Sanford Health Bemidji a chance to recruit more residents as employed physicians than they could do with their own residency programs, according to Walsh.

"If Sanford Health Bemidji had an emergency medicine residency, it would be a three-year program and probably have a couple of residents each year," Walsh says. "Every three years, there would be about six residents who came through Bemidji, and you may or may not be able to recruit all six of them to remain in Bemidji."

With the rural rotation program, Sanford Health Bemidji is working with 12 emergency medicine residents per year.

"In one year, there is the potential to recruit about six ER doctors at lower cost and lower investment than an in-house emergency residency program," Walsh says. "This allows Bemidji to put its energy into faculty recruitment and boost physician recruitment in general because physicians get to teach."

Carilion Clinic has managed its stretched hospital bed capacity with a command center and post-acute referral hub.

Carilion Clinic has mastered the intricacies of operating a command center and post-acute referral hub that manages patient transfers and efficiently transitions patients out of its hospitals for post-acute care.

Like many health systems across the country, Carilion Clinic is grappling with patient volumes that stretch bed capacity. Under these circumstances, managing patient flow and patient transfers into and out of the health system are crucial.

"We have real-time assessment of every hospital bed in the health system, including emergency departments," says Paul Haskins, MD, SVP medical director of the Carilion Transfer and Operations Center. "So when you have an enterprise command center, it has all aspects of patient flow, including a real-time situational awareness of the primary drivers of hospital systems, which include the transfer process into the system, the operating rooms, and the emergency departments."

Carilion Clinic's command center and post-acute referral hub are focused on streamlining.

"You have people and technologies, and you use them together to streamline the processes to affect patient care," Haskins says. "To have an efficient process for transfers, you must have physician-to-physician communication. In the beginning, you put the right physicians on the line, then you eliminate any sort of communication that is duplicate."

The command center manages patient transfers into and out of the health system.

"We receive transfers into our health system from several health systems," Haskins says. "We send out transfers for a few conditions such as burns, pediatric cardiology, and some transplants. It is about making the transfer process smoother—whether it is into or out of our health system."

The post-acute referral hub helps Carilion Clinic manage length of stay.

"When we look at length of stay, the patients who go to a long-term care facility or a rehab facility tend to have the longest length of stay, which makes sense based on patient needs," Haskins says.

By eliminating duplication of processes, the post-acute referral hub can streamline processes, according to Haskins.

"By having the paperwork in a repeatable and consistent environment and having relationships with different facilities, then you can streamline processes based on a mutual agreement that the facilities will take patients and trust builds up over time," he says.

Paul Haskins, MD, is SVP medical director of the Carilion Transfer and Operations Center at Carilion Clinic. Photo courtesy of Carilion Clinic.

Staffing models

To make its command center and post-acute referral hub cost effective, Carilion Clinic leadership focuses on the right mix of healthcare professionals. The post-acute referral hub poses an easier staffing challenge, with the assignment of case managers and social workers. The command center, meanwhile, has been more challenging because of the question about whether a physician needs to be on the staff.

"A big question is do you need a physician in the command center to review transfers and see whether patients can stay in their facility," Haskins says. "It is about a $1.5 million expense to have a physician in the command center at all times."

After considering the question, leadership decided to staff its command center with registered nurses who have either ICU or emergency medicine training.

"If you have a physician on the line, then that is a huge expense," Haskins says. "The nurses are experienced, so they know who needs to be on a phone call and how to streamline the process. So the right phone call goes to the right specialist or the emergency department 99% of the time."

"You can scale up and scale down [the number of nurses needed], depending on the size of your health system and how many facilities you are overseeing," Haskins adds. "We oversee seven of our own hospitals. So we have anywhere between six and seven RNs in the command center most of the time; in the middle of the night, we will go down to three."

Benefits of command centers and post-acute referral hubs

The command center concept offers health system leadership several benefits.

"We have improved transfers into our health system, [and] we have also streamlined the transfer process out of our health system when it is necessary," Haskins says. "We have also decreased length of stay compared to national benchmarks."

The post-acute referral hub has generated gains in patient satisfaction, but the biggest benefit is in improving patient flow.

"We have patients who come to our hospitals, but it is not the input that is the problem; it is the output," Haskins says. "You must do the best job that you can to streamline the discharges out of the hospital."