Health care providers employed by North Carolina’s Piedmont Health Services (PHS) are awaiting the results of their union election, a pivotal step that is part of their larger push to address challenges that impact their ability to properly care for their patients. Their efforts are part of a larger trend. For health care workers nationwide, the pandemic has fueled a wave of labor organizing that seeks to address longstanding workplace issues that were exacerbated by COVID-19.
In an overwhelming show of support, over 70% of PHS’ eligible voters signed union cards. Many of the providers behind the organizing efforts are women in family medicine and sexual and reproductive health care whose patients come from marginalized communities and experience far better health care outcomes when they receive continuity of care. Six providers who spoke to Prism say that PHS’ “systemic inefficiencies” push talented and passionate providers out and hinder existing providers from delivering on PHS’ mission to provide high-quality health care to low-income and uninsured residents, including undocumented patients with few other health care options in central North Carolina.
Filling crucial health care gaps
PHS is a Federally Qualified Health Center, which the Health Resources and Services Administration defines as a community-based and patient-directed organization that “deliver[s] comprehensive, culturally competent, high-quality primary health care services to the nation’s most vulnerable individuals and families.” For more than 50 years, PHS has provided some of the most comprehensive health care in Alamance, Caswell, Chatham, Lee, Orange, Person, and Randolph counties—regardless of a person’s ability to pay, their insurance status, or their citizenship status.
This is what drew Rebeca Alejandra Moretto to PHS. Moretto, who previously worked with farmworkers, has been in the North Carolina birthing community since 2008. She was a doula and midwife assistant before becoming a certified nurse midwife. In nursing school, Moretto did a clinic rotation with Helen Mikul, one of PHS’ most revered and longstanding providers.
Mikul’s story is an interesting one. Her family moved to Mexico in the 1960s when she was a child, and they were detained and deported twice. In each instance, women in the nearby village made sure Mikul’s family had food to eat while they were detained. To this day, she’s unsure of how she, her pregnant mom, and three siblings would have survived the ordeal without the kindness of the local women. Back in the U.S. in the 1970s, Mikul attended high school in South Texas and became fluent in Spanish. At the time, she was unsure of the direction her life would take, but she knew that she wanted to help Spanish-speaking immigrants in the U.S.
Mikul went to nursing school when she was 34 years old and became a certified nurse midwife at 40. She has worked with PHS since 2008, devoting herself fully to serving Chatham County’s immigrant community. Despite her stellar reputation among patients and other providers, Mikul says she can’t quite shake the feeling that PHS’ management sees her and other providers as “disposable.”
“I appreciate Piedmont letting me do what I love to do and serve underserved and uninsured immigrant communities, but I know from experience that they don’t support providers appropriately,” Mikul said. “It’s always just more demands and more demands and less and less support. I can’t even call out sick. If I have 23 patients in a day, there’s nobody to see them, and then there’s no place to put them. I know I’m not disposable, but that’s not how I’m treated.”
Moretto said watching Mikul provide high-quality midwifery to immigrant patients—despite all of the limitations she was up against—was a “life-changing experience.” Moretto knew working at PHS wouldn’t be easy, but she made good on a promise to Mikul that she would work for PHS when she was done with school. Moretto now works at PHS’ Moncure Health Center, a site that has historically been without a midwife.
North Carolina ranked 36th in the country for infant mortality in 2020, and there are 18 counties that lack any kind of maternity care. Midwives can fill these deadly gaps, but as of 2019, North Carolina is one of just four states that require a certified midwife to have a supervising physician, creating obstetrical deserts and insurmountable barriers for medical professionals who want to provide care in rural areas. Moretto—a native Spanish speaker who provides culturally competent care—is a godsend to rural communities like Moncure. But PHS employees say that members of the health system’s management team—including CEO Brian Toomey—don’t seem to value the insights of providers like Moretto, who are experts at navigating challenges and can offer unique insights into how PHS could better serve its patients.
“As providers, we’re very passionate about providing excellent care and we know that resources are limited, but what we’ve been asking for are very reasonable things, like transparency and communication and supplies that are easy to obtain and would provide improved access to care,” Moretto said. “Decisions are made for us about how we’re going to function in the clinic and about the way we’re going to take care of patients. [PHS management] doesn’t consider our input, and I’ve seen patients suffer because of it.”
Moretto said she often thinks about a statement one of her colleagues made: “There isn’t a day that goes by that they don’t apologize for the system.”
“I don’t want to be embarrassed by the care that we provide, and I don’t want to feel guilty that we can’t provide better care for our patients when we know that it’s actually possible. A union provides an opportunity to come together and have a collective voice in how decisions are made,” Moretto said.
‘Discriminatory’ scheduling issues
A primary reason workers unionize is to negotiate and enforce a contract with management that guarantees higher wages and better benefits, but PHS providers have been clear that they are content with their salaries. What they really want is a seat at the table when it comes to making organizational decisions that affect how they deliver patient care—including having a say in how scheduling is done at PHS’ health centers.
“Scheduling” sounds like a relatively small and easy-to-fix issue, but it’s an issue that came up with each of the providers Prism spoke to. Given PHS’ patient population, Moretto said it’s even more important to be “incredibly mindful” when it comes to scheduling and respecting people’s time. Many patients don’t get paid time off or can’t take time off work to go to the doctor; others don’t have transportation or access to child care. Moretto said she doesn’t always know when she will be able to see a patient again, so when she has them in for an appointment, she needs to be able to spend as much time with them as possible—and this time together goes a long way in helping to build trust.
“I’ve taken care of pregnant people who’ve had two or three pregnancies and over time—because I’m speaking to them in their language and giving them all the time I can—they begin to open up to me and disclose stories of sexual assault and domestic violence,” Moretto said. “‘Efficiency’—or at least how PHS defines it—runs counter to what it requires to create an environment where people feel safe and heard. That takes time, but when we take the time that patients need, it becomes a management issue, and we are told we need to be more efficient in the way that we take care of people.”
The midwife said PHS’s approach to scheduling reminds her of something preschool teachers say: You get what you get, and you don’t pitch a fit.
“The way our scheduling is done puts our patients in a position where they just have to settle for less, and that’s not equitable; it’s actually discriminatory,” Moretto said.
Danielle Drobot, a family nurse practitioner at the Carrboro Community Health Center and a member of the union’s organizing committee, said that PHS’ “inappropriate scheduling” creates patient backlogs and extra work for providers.
When PHS providers see a new patient for the first time, they have 20 minutes for the appointment. Drobot said these appointment slots don’t allow for much beyond a “meet and greet” and a short conversation about what the patient’s primary concerns are. If new patients have complex needs—related to opioid use disorder, for example—setting them up with medicated assisted therapy and doing the appropriate paperwork for a prescription to addiction treatment medication can take well over an hour. This means that other scheduled patients may not be able to see their doctor that day because they only had a small window of time before having to return to work or pick up their children from school.
Drobot said that patients are complex and face multiple barriers to care, which means as a provider, she needs to be able to address as much as she can in each visit because she understands it’s often difficult for patients to come back for multiple return appointments.
“With some additional training for schedulers and provider input about how long new office visits should be, these issues could be easy to address. But that’s not how it is, and at the end of the day, it falls on the provider to follow up with the patient and make sure they’re OK,” Drobot said. “If the systems around us are failing, providers have to pick up the slack—whether that means making phone calls after hours or staying at work late. We are team players and are happy to do this in order to meet the needs of our patients, but we hope for system changes that will support our work and not add to it.”
Hurdles, barriers, and workplace issues
Dr. Fareedat Oluyadi also cares deeply about providing equitable health care access to PHS patients, which is why she signed a union card. The provider said that on any given day, she has to navigate a series of hurdles to provide patients with the care that they need, and she hopes that a union will allow providers to work with management to address the health system’s many infrastructure issues.
Oluyadi is basically a unicorn in her field. The Siler City-based doctor is part of the small minority of family physicians who practice obstetrics. Oluyadi is particularly interested in reproductive health, rights, and justice, and though less than half of medical schools offer students hands-on clinical experience with abortion, Oluyadi obtained this training and is anxious to provide full-spectrum reproductive health care, including abortion care. She’s not had the opportunity. The doctor came to PHS in 2020 specifically to care for high-risk obstetric patients, but she said the structure needed to “properly and respectfully care” for these patients is “severely lacking.”
“A lot of the issues pertaining to access to care are really woven in with systemic bias and racism, and at Piedmont Health Services, we as providers really want a seat at the table to help decide how resources are being used,” Oluyadi said. “Family medicine doctors like me, who’ve devoted their lives to providing care to marginalized populations in underserved areas, experience so many setbacks to providing the care that’s needed because we don’t have the workplace conditions that allow us to see the patients we need to see and we don’t have the structure to provide the care they need or the resources, equipment, or funding to build out the infrastructure.”
At the Carrboro Community Health Center, there have been times when providers found out at the time of a patient appointment that the electrocardiogram (EKG) machine was malfunctioning. While the machine always gets fixed, it can cause a significant delay in patient care. Ideally, PHS could develop a process to work with providers to check and troubleshoot these systems before patients arrive for appointments.
“Patients already have enough barriers to care,” Drobot said. “Patients experience language barriers, transportation barriers, and a number of social and personal hardships. Things are hard enough and what they don’t need is a health care system that makes their lives harder. We want to make simple improvements to the basic functioning of the clinic that can go a long way in maximizing time and resources.”
Moretto is particularly concerned about how these barriers impact her high-risk prenatal patients. For her many pregnant patients who have gestational diabetes, for example, or are over the age of 40 or have a BMI over 40, the American College of Obstetricians and Gynecologists recommends “fetal surveillance” in the form of a nonstress test to monitor fetal well-being. Essentially a little monitor is placed on the pregnant person’s belly, and Moretto said that by checking the fetus’ baseline heart rate, the nonstress test is a simple way providers can make sure the pregnancy is going well. The problem is that the monitor at the Siler City Community Health Center was broken until recently, and the Moncure Community Health Center doesn’t have one at all.
A nonstress test is a very simple service the clinic should offer, but instead, Moretto and other providers have to schedule patients elsewhere to get the test done. This is also true for lab work. Because the Siler City clinic is short on phlebotomists, patients have to get their blood work done elsewhere, which means patients without transportation who arrive at appointments with their children then have to figure out how to get to another location to get their labs drawn.
For a time, Moretto tried to prevent patients from having to go to another site by drawing labs herself—until management told her to stop. Complicating matters further, many of PHS’ patients are referred to the UNC Health system for additional care, but because PHS is perpetually understaffed, they are unable to send patients’ medical records to UNC Health providers in a timely fashion.
“As providers, we’re experiencing this really intense level of moral injury,” Moretto said. “Every day we are struggling with whether we are doing enough for our patients. I can’t even talk to my friends who work in private midwifery practices because they can’t relate at all to what I experience at PHS.”
“A different mechanism for progress”
The pandemic fueled a wave of labor organizing among frontline health care workers, and while Oluyadi said Covid-19 was a “powder keg” for PHS’ union, it’s not the full story.
“The pandemic added more stress to our already very stressed and stretched-thin system,” the family physician said. “All of our systems and lines have been burned out. I’m one of the newer providers, and this is a place I want to stay, but it’s hard when over and over again, I hear of another beloved colleague’s resignation. It feels so sad because these are people I know, and I know they love what they do and they want to be here, but they can’t be their best self here anymore. They don’t get the support they need, and they are completely burned out.”
Mikul told Prism that she’s seen somewhere between 20 and 25 providers leave the health care system—and the nursing department sees especially high turnover. Mikul claims one nurse recently left because PHS made some changes to employee insurance benefits, causing her monthly insurance cost to skyrocket.
Health care work is stressful even under ideal circumstances, Mikul said, but when you add “out-of-touch management,” a lack of “basic resources,” and “scheduling nightmares,” the work becomes unmanageable. When Prism spoke to Mikul in late January, her appointments were booked out for a solid month, and she didn’t have a single slot available for a same-day appointment.
“I’ve lasted this long because I have a high tolerance for bullshit,” Mikul said. “For me, this isn’t just a career or a job; it’s my calling. I would do this work no matter what, so I’m committed, but that doesn’t mean I should have to put up with everything I put up with.”
Mikul, who is 63, plans to retire in the next two years, but she’s joining the union fight because she wants PHS to be a better workplace for providers so that PHS will stop “bleeding talent.”
Emily Headrick is one of the many providers who recently left PHS. Headrick joined PHS in 2016 as a nurse practitioner at the Burlington Community Health Center and served as lead provider of the organization’s COVID-19 response. She left PHS in recent months to work for an international non-governmental organization. Headrick told Prism that providers like her who specifically seek out jobs at Federally Qualified Health Centers understand there are universal challenges with health care and with social determinants of health that they are prepared to navigate, but she said it’s important to distinguish those challenges from “unnecessary challenges” imposed on providers by their workplaces.
“The hardest part of our jobs should be addressing the socially and medically complex needs of our patients; it should not be navigating a lack of structure and high staff turnover because management keeps plugging good and talented providers into a weak system,” Headrick said.
During her time at PHS, the nurse practitioner said there was consensus between management and staff that there needed to be more training and a more comprehensive onboarding system for new providers and staff members. But despite what she describes as “robust support” and the availability of comprehensive technical assistance material to guide onboarding and training of new providers, management reportedly never took any tangible steps to invest in training and onboarding that could promote retention and reduce turnover. High turnover doesn’t just impact staff morale; it impacts patients’ health.
“We see progress in health outcomes and health indicators when patients trust their health care team and trust that we’re going to be there for them for the long haul. They can see we’re invested in their growth and development,” Headrick said. “When there is high turnover, it erodes trust in our team and in our institution, which is a fragile thing that we’ve spent decades earning.”
The nurse practitioner told Prism it’s telling that providers who have been at PHS for decades are supporting the union.
“I think they understand things have gotten to a point where they need a different mechanism for progress,” Headrick said.
Labor organizing in North Carolina isn’t easy. North Carolina law bans government agencies from making contracts with unions and bans public employees from striking, which may explain why the state is second-to-last in its number of unionized workers. Only 2.7% of North Carolina workers are unionized. PHS providers who spoke to Prism are concerned by PHS’ actions against the union thus far.
On Nov. 23 when PHS physicians and medical providers petitioned the National Labor Relations Board to form the Piedmont Health Services Medical Providers United and submitted a petition to CEO Brian Toomey, PHS responded by hiring Ogletree, Deakins, Nash, Smoak & Stewart, a law firm with a reputation for union-busting—especially in North Carolina. Duke University hired the firm when Duke University Press (DUP) employees announced their intention to form a union last year.
Mikul shared an email with Prism that PHS’ chief financial officer, Lydia Mason, sent to providers. According to Mikul, the message had “classic anti-union talking points.” The email read, in part, “While I support the legal right of all employees to decide whether or not they want a union to speak for them, I am extremely concerned about statements the PHS Providers United union continues to make about what union representation would mean. Much of what they say is simply wrong under Federal labor law, and my fear is that once providers come to understand what having a union really means, it will be too late, and some may leave. Hiring new providers willing to work under a union contract and in a unionized setting could be very difficult.”
PHS has also taken union organizers to court, arguing the job functions of union members are too different to bargain together and that medical providers are indeed supervisors, making them ineligible to unionize. PHS also contested the use of mail-in ballots for the union’s election during the pandemic, arguing that providers should have to vote at their places of work. The National Labor Relations Board ruled in the union’s favor on all counts, allowing them to move forward with their election. Ballots were mailed out Feb. 4 and will be counted March 7. Legally, PHS could try to delay the process further by contesting parts of election or impounding ballots, but Dr. Michaela Mccuddy, a union organizer and family medicine specialist at PHS’ Siler City Community Health Center, told Prism she’s trying to remain hopeful management will “respect this democratic process.”
Toomey would not respond to specific questions about PHS’ operations or the allegations made by providers. In an emailed statement to Prism, he wrote that PHS is limited in how they are able to respond to media inquiries “[s]ince employers’ statements and actions are under close legal scrutiny in the days immediately preceding a National Labor Relations Board election and PHS does not want to do or say anything inadvertently that could result in the election being overturned.” The CEO went on to say that PHS “is committed to protecting providers’ right to have a secret ballot vote conducted by the National Labor Relations Board to decide whether or not they will be represented by a union, and PHS has a responsibility to ensure that providers are fully informed about the implications of their decision so they can decide what is best for themselves and the patients and communities PHS serves.”
Oluyadi told Prism that the last several months working at PHS, she realized management was ignoring her concerns about the conditions she faces as a provider, leading her to have a “complicated relationship” with her work.
“It’s a love-hate relationship. When I’m at work, I’m really stressed out and frustrated by the conditions and I want to run, but when I’m off I think of my patients and I miss them,” Oluyadi said. “When we try to talk about what we’re up against, we get gaslighted and told things are not as bad as they seem or that we’re overreacting or that the pandemic should be our focus. So in that way, the union has been really therapeutic. I’m in community with my colleagues in a supportive way, and we are fighting together to fix these issues that impact the patients that we love. It feels very liberating, and it’s the first time in a while that I’ve felt hopeful about my workplace.”