US healthcare:

The earth shook when the American Medical Association announced in June that it was going to form a national union for doctors. The announcement, though amazing in its own right as a sign of the profound change that managed care has brought to the most conservative medical organisation in the US, belies the difficulties that lie ahead if the AMA is to proceed down this route.

Technically, the measure, which has been adopted by the AMA's house of delegates, still needs the approval of the board of trustees, but given the media attention the AMA has already received, it will be difficult to go back.

The AMA has fought against efforts to introduce national health insurance since the 1930s, opposed the introduction of Medicare and was generally against any programme or insurance scheme that would come between a doctor and a patient - but it has now changed sides. This is quite amazing.

There is no question that the medical profession in the US has lost a significant degree of autonomy and professionalism through its dealings with insurance companies and the restrictions placed on the activities of doctors by managed care companies and government.

The denial of surgical procedures (in the name of cost control) and the requirement to get even the most basic treatments approved by a representative of a managed care company has been a major thorn in the side of American doctors for the past decade.

The growth of managed care has served only to exacerbate the problem. Doctors have looked at alternative strategies to deal with the situation.

It should also be noted that the AMA has had two woeful years. It has been losing membership steadily, it made a tremendous gaffe with an ill- conceived plan to endorse the products of a private corporation (Sunbeam) for which it is still being sued, and, most recently, it drew scorn for firing the editor of the Journal of the American Medical Association for publishing an article that seemed to be politically motivated.

The AMA, which has been losing money, sees potential benefits from forming a union in increased income from dues. Many independent doctors have expressed interest in joining a union and several traditional unions have expressed interest in organising doctors, among them the Service Employees International Union (which represents other health workers), the United Food and Commercial Workers, and the American Federation of Teachers.

But there are significant legal barriers to organising doctors in the US. Only employees are allowed to organise, according to National Labor Relations Board regulations. Junior doctors are considered to be students and therefore not allowed to bargain collectively except when they work in public hospitals or when a private hospital agrees to allow them to unionise.

But these doctors make up little more than one-third of all doctors in the US. The largest grouping, the nation's 400,000 self-employed doctors, are the ones who have suffered most under managed care, but they are also ineligible for unionising under current law. The AMA said it would lobby Congress to change the law, and a bill has recently been introduced to this end, but it is unlikely that it will progress.

The AMA, in its announcement, said it had decided that its union would never strike. This does not seem to have satisfied either members of the profession or the public, as letters to the editors of major newspapers and TV reports indicate.

But if they won't strike, they can only influence managed care companies and government by garnering significant market share in local areas - not something that will be easily accomplished.

There is great sympathy for the idea of freeing doctors from the clutches of the managed care companies and restoring their autonomy - if not for increasing their incomes. Several states are considering - and Texas has passed - legislation that allows doctors to bargain collectively (though not to call themselves a union).

While the AMA has called for immediate organising to begin, it is far from clear how successful it will be or why doctors would opt for membership of an AMA union rather than a traditional one.

It is clear that this development has more to do with doctors expressing their frustration at the state of medicine in the US at the end of the century than the virtues of union solidarity.

Howard Berliner is associate professor and chair of health services management and policy, New School of Social Research, New York.