One appointment slot. Two patients booked. A frustrated MetroHealth Medical Center primary care provider trying to meet the needs of both, who often have complex medical conditions. So much to address. So little time.
This is one of the reasons doctors, nurse practitioners and physician assistants in primary care at MetroHealth say they formed the Primary Care Providers Union (PCPU). The hospital routinely double-books patients without warning, the healthcare providers say. The practice has led to hectic schedules for them. Even more important, it has impacted the quality of patient care, they say.
“It’s frustrating to be a provider wanting to take care of all your patients’ needs but having to choose what’s the most important to address at today’s visit, because there’s not necessarily enough time to do it all,” said Amy Catalani, a certified nurse practitioner in internal medicine who is part of the unionization effort.
The MetroHealth doctors are part of a growing national trend: physicians unionizing. Union membership for them is increasing as the overall percentage of U.S. workers belonging to unions has slipped, according to federal data. Doctors across town at University Hospitals began organizing last year, and concerns about patient care were among their reasons for wanting a union.
In late April, the primary care providers notified MetroHealth officials that they had unionized through AFSCME, which represents state and local government employees. The hospital still hasn’t responded to any requests relating to the union, said Dr. Vikas Gampa, the primary care physician leading the unionization effort.
MetroHealth would not discuss the primary care providers’ unionization effort, a spokesman told Signal Cleveland.
MetroHealth did explain the hospital’s rationale for double-booking visits.
“High no‑show rates often leave gaps in schedules while many patients are still waiting for timely care,” a MetroHealth email to Signal Cleveland states. “Many of these missed appointments stem from real challenges in patients’ lives – childcare needs, transportation barriers, work constraints, unexpected family responsibilities and more.
“Using data to thoughtfully add overlapping appointments helps offset those gaps so more patients can be seen when they need it,” it states. “This approach is widely used across healthcare.”
The healthcare providers remain “resolute” in their unionization effort, Gampa said. They continue to organize and press for quality-of-care changes they believe will benefit patients and providers, Gampa said.
Although union membership among doctors is growing, the percentage is still small. About 8% of doctors nationally belong to unions, according to census and Bureau of Labor Statistics data. Though a small percentage, it has inched up in the last decade. About a decade earlier, roughly 5% of doctors were unionized. Overall union membership, at 10% in 2025, was about 11% a decade earlier.
“It doesn’t sound like a lot to say that 8% of doctors are unionized in the United States,” said John August, program director of the Partners Program at Cornell University’s ILR Scheinman Institute, who is an expert in labor relations in healthcare. “It used to be almost unheard of that the word doctor and union would even be used in the same sentence.”
More U.S. doctors are joining unions. Why?
Higher wages and better benefits are the bedrock of unionization campaigns in most sectors. Those aren’t the reasons most doctors and advanced practice practitioners, such as physician assistants, choose to organize, August said. These medical professionals are more concerned about such things as improving the quality of patient care and having more say in workplace policies that affect them or their patients. They want input into setting the workload and pace of providers’ schedules, which include practices such as double-booking patients.
Changes in healthcare are fueling the unionization trend, August said. This includes the corporatization of healthcare, which can start with hospitals or corporate entities acquiring hospitals and medical groups. As the number of hospitals within a system grows, this can result in decisions – such as those regarding patient care – moving further away from those who work directly with patients, he said.
“Doctors want to reassert their ability to make decisions for their patients as opposed to having them made in some unseen corporate or other office which is telling physicians how they should practice medicine,” August said. “Unionization is the only way that doctors are going to be able to reassert that kind of patient-focused autonomy.”
The increasing number of doctors who have moved from private practice to becoming hospital employees has also spurred more unionization efforts, he said. More than 80% of doctors are employed by hospitals or corporate entities, a 5.6 percentage point growth in the last two years, according to a recent report by the Physicians Advocacy Institute and Avalere Health. Being an employee “gives them much less power,” August said.
Government funding cuts have particularly affected safety-net hospitals such as MetroHealth, which provide care even when patients can’t pay. MetroHealth had projected a $27 million deficit for 2025 until unexpected state Medicaid payments wiped it out, MetroHealth President and CEO Dr. Christine Alexander-Rager wrote to staff in February.
The projected loss for 2025 had been $100 million, she wrote, before the hospital implemented cost-saving measures. The Medicaid payments and the belt-tightening resulted in the hospital having operating income of about $56 million. Alexander-Rager cautioned that remaining in the black wasn’t a given because of a few factors. They include MetroHealth’s day-to-day operations costing more than the hospital brings in and the uncertainty of the future of some state Medicaid funding.
When hospitals implement changes in response to financial constraints, primary healthcare providers and doctors in specialties where there are shortages risk being particularly affected, August said. This is why health care providers from certain specialties tend to start unionization efforts.
“We have acute shortages in primary care, pediatrics, gerontology and internal medicine,” he said. “Those are the specialties which really need the most support and get the least support.”
MetroHealth providers say unionizing leads to better patient care
It isn’t surprising that MetroHealth primary care providers were the ones who decided to unionize.
These healthcare professionals say that patient care changed post-COVID. Because many patients avoided seeing doctors during the pandemic, they were often sicker when they returned. Also, with urgent care and express clinics becoming popular, healthier patients are opting to use them. This is especially true when it is difficult to get an appointment with a primary care provider, the providers interviewed said.
“The patients that we’re seeing are more for chronic disease-state management, chronic care,” Catalani said. “They’re not those quick appointments where you’re coming in with one specific complaint.”
Then last year, MetroHealth started double-books without first seeking input from primary care providers, said Gampa, a doctor who works in the Pride Clinic, which focuses on LGBTQ+ patients. For example, he said providers generally know which patients tend to miss appointments. Therefore, double-booking their 20-minute slots would tend not to be as problematic.
But with the system currently in place, two patients often show up, he said. It isn’t uncommon for providers to have a few double-books per week, Gampa said. In order to meet all of the 20-minute appointments for the day, he said, providers work late or cut in-person appointments short and follow up by telephone.
Not having enough time to spend with patients, especially those with multiple conditions, undercuts the quality of care, Gampa said. He recalls an appointment with a patient who had multiple conditions, including heart disease, lung issues from smoking, substance abuse and a recent problem with his hand. Gampa knew that after addressing the patient’s heart and lung issues, there was only time to address one more.
“It’s a matter of my clinical judgment, but it’s also the patient’s perceived importance of certain things,” he said. “So, we talked about the hand thing, because that’s important to them and their livelihood. But then we haven’t talked about the alcohol use or the substance use.”
Not addressing each of the patient’s concerns made him feel “really sad and heavy,” Gampa said. He said the patient could sense it, and felt the same way.
Heather de la Pena, a certified nurse practitioner in family medicine who is part of the organizing effort, can relate to Gampa’s frustration and anguish. She laments the patients’ conditions she can’t fully address because of visit time constraints or because they can’t get in to see her because she’s overbooked.
“It’s gut-wrenching,” she said.
After the policy was implemented, providers began meeting with their primary care medical directors to raise concerns about the double-books and the heavy workload they said was undermining patient care and leading to burnout for many of them. They also came with solutions, de la Pena said. She said the medical directors listened – but didn’t act.
“Listening is not enough,” de la Pena said. “We need to see the changes.”
The providers have also met with hospital officials about double-books and workload since forming the union. Gampa, de la Pena and Catalani said they consider MetroHealth officials to have been less than transparent about the underpinnings of such practices.
MetroHealth doesn’t see it that way.
“Our providers have meaningful opportunities to engage in decisions that support patient care, and we will continue to welcome their feedback on all aspects of their experience at MetroHealth,” states the hospital’s email to Signal Cleveland. “That’s something MetroHealth President and CEO Christine Alexander-Rager, a family physician, is especially passionate about.”
The email says that the hospital is working on implementing tools to lessen the workload of primary care providers, including ambient AI to assist with documentation. Ambient AI is being used in healthcare to passively listen to patient-provider conversations and then generate medical notes.
MetroHealth providers asked the hospital to recognize their union
Once employees form a union, they have to get their employer to recognize it. This can be done through a voluntary recognition agreement in which a union asks to be recognized and the employer agrees. Unions can also file for election.
The Primary Care Providers Union asked MetroHealth for voluntary recognition in April, but the hospital has not responded, Gampa said. The union also filed for an election with the State Employment Relations Board (SERB), according to agency records.
Last year, doctors at University Hospitals began organizing to form a union. Signal Cleveland contacted the Doctors Council, which is part of SEIU, to learn the status of the organizing campaign. A spokesperson declined to comment.
UH pediatricians Dr. Lauren Beene and Dr. Valerie Fouts-Fowler led the effort to unionize doctors. The hospital soon fired them. The union filed an unfair labor practice complaint with the National Labor Relations Board, saying the doctors’ firing was unjustified. The case is pending. UH has said that Beene and Fouts-Fowler were fired for misusing an internal hospital messaging system. Organized labor, patients and others have held demonstrations at UH facilities in support of the fired pediatricians.
MetroHealth providers love their jobs but still want a union
The doctors and advanced practice practitioners in primary care at MetroHealth have in-demand careers, which give them many employment choices. Still, they never considered leaving because they said they are drawn to practicing at a public, safety-net hospital. They see making things better with a union as their only option for improving conditions.
One four-letter word came up when Catalani, de la Pena and Gampa described their work. It wasn’t a bad word.
“I love Metro,” Gampa said. “I love the patients. I love making those relationships with them. And the more you love those things, the harder it is when you can’t provide the care that you feel they deserve.”
Providers often can’t leave a hectic workday at the hospital. Evenings and nights are spent responding to MyChart messages or catching up on (digital) paperwork that was impossible to complete during no-breathing-space days, often because of double-books.
Evenings at home can often find Gampa cradling his infant son and completing work tasks on a mobile phone in one hand. As de la Pena completes work at home, her young children ask, “Mommy, why are you always working?” Catalani wants to give undivided attention to her mother, who has severe dementia, when she visits her in a nursing home. Work matters often compete.
Even patients remark about the primary care providers’ packed schedules. Catalani remembers responding to a patient’s MyChart message at 10:30 p.m.
“‘I’m sure, you know, sleep is important,’” the patient wrote back. ‘You should be getting some rest. So, thank you very much for your message, but I just need you to go get some sleep.’”
