Picking a team: The hospital or private practice?

Some of us are part of "the 25%," a dying breed known as private-practice cardiologists. We didn't know that we were in danger of extinction until it was already thrust upon us. The Annals of Internal Medicine article on August 23, 2010 pointed out the latest White House recommendation that physicians join hospitals or large group providers in the wake of health care reform.  Prior to this revelation, we were under the impression that physicians would always remain in one of two historic categories—academic or private practices, a choice driven by one's orientation toward either research or clinical medicine. It is now crystal clear that the shifts in reimbursement and other factors have driven hospitals out of the woods and into the open to hunt for laborers, and President Obama has sounded the horn, signifying the beginning of the greatest  fox hunt in medical history.

Physicians now find themselves with different agendas and are now to become cheerleaders or mascots for the "hospital team" or the "private-practice team." Because hospital boards can suddenly become padded with more employees than private-practice physicians, it can become very uncomfortable for everyone. The new division doesn't work very well in a world where private practice still exists and where some of us don't have the DNA it takes to easily add to our focus on patients the daunting task of including the hospital's bottom line. I don't think this discomfort extends to those who have been employed by a hospital for a very long time, although I could be wrong. They seem to be going about their business taking great care of patients as if nothing ever happened, a luxury in today's medical environment.

Some hospitals have been forced to recruit private-practice physicians because they are suffering from gigantic top-heavy overhead costs, and other facilities, previously nestled in a comfortable economic niche, have had their rhythm disrupted by things beyond their control. Local financial tragedies including factory closings and multiple foreclosures in their community work forces have taken their toll. The pool of money that came from hardworking patients who "pay a little along" on their hospital bill has all but vanished. Medicare continues to whittle at reimbursement, and families can no longer afford expensive third-party-payer insurance programs.

Those of us who remain in our private offices view physicians who are contemplating a change as potential slaves walking toward massive ships, forced into servitude by factors such as school debt, a downturn in local economics, and, in rare instances, extremely poor financial choices. Very rarely, it's simple greed that drove the change. Some are bailing from private practice because the comfortable situation that allowed for the building of massive office structures and the purchase of the best medical equipment money could buy have had the rugs pulled out from under them by the recession. Like subsidies that disappeared from farmers decades ago, the decrease in Medicare reimbursement caused some physicians to no longer be able to conduct their practices in the manner in which they were encouraged to practice. The recession has now reached into our profession and has a firm choke hold on it and, like Harry Potter Dementors, is hovering over many others, ever threatening to take the practice lives of so many, leaving an empty shell where a thriving place of healing should have stayed. No matter what the cause, the end result is a tragic extinction of the private-practice physician.

Sometimes, leaving private practice to work for a hospital is a marriage made in heaven. It garners a huge lot of cash at first, sometimes with a nice sign-on bonus to ease acute financial distress, provides an office with a ready-made staff (although often not of your own choosing), and guarantees an income to pay back the enormous debt incurred while trying to get through med school. In other instances, it saves physicians from an embarrassing turn of events like public foreclosure. It's not easy for young doctors now to pay back their debt, as it was 30 years ago, and the debt is actually larger than it used to be, so one might understand the circumstances that would invite hospital employment.

In many instances, though, the changes aren't always optimal. When old private practices are fractured, hospital administrations are sometimes shocked by impact it can have on a community of physicians. Those who choose to remain in private practice feel the sting of ingratitude. Many groups have sponsored tens of thousands of dollars worth of ventures such as board exam attempts and subspecialty exams for their associates, covered their practices for multiple courses to become boarded in other subspecialties, built enormous buildings, and purchased equipment specific to those new qualifications only to have those associates take those qualifications and become a cheerleader for the other team. Sometimes, shifts in practice patterns can occur driven by the need to justify an enormous salary, such as those who have headlined in the news recently. It is also tragic to see someone struggle underneath a stress level garnered by new work pressures that no human being should be forced to endure. Other newly employed physicians have outright lost their jobs after a short few years because of the agendas of long-term hospital employees and even personality clashes with techs made worse by short-sighted CEOs. Many that I've spoken with are unhappy at the loss of autonomy, needing to reach a certain quota of patients for the day or unhappy with an office staff that they were unable to train or influence. These pressures endanger the passion for the practice of medicine, a passion stolen by the daily grind of guaranteeing the bottom line or the need to satisfy the personal agendas of some.

The focus of the old successful private-practice physician, now nearly extinct, is not the hospital bottom line, and it's truly not even their own personal bottom line. They practice medicine for the joy they feel in promoting comfort and healing. The obsession with the patient's "length of stay" is trumped by the patient's "need to stay" in the hospital setting. "X number" of stress exams, echoes, or caths are not required to justify a salary like we've heard of recently with those cases now going to trial. The ideal private practitioners are not persuaded by lucrative medical sidelines and the lure of device companies that pad their bank accounts. Successful private-practice physicians are happy in their work but the fairy-tale era of considering only what is best for the patient is rapidly coming to an end. Sadly, only "socialized" medicine, where everyone is employed by the hospital, a minion of their nation's government, seems to be the only place where all physicians will coexist peacefully but likely unhappily in the future.

I am grateful to God that I was able to spend 20 years in the practice of cardiology when patients were happy, physicians were happy, and hospitals were thriving. None of my younger colleagues will ever know what that was like. They will spend the better part of their practice lifetime in the midst of this ugly transition, in either a constant tug-of-war between the priorities of the private practitioners and those employed by the hospital or affected by those who cherished their years of private practice in the shadow of the dread of socialized medicine. I pray that we can all find a way to comfortably navigate this new course, and I hope that the patient will always remain the focus, no matter what team we find ourselves playing for.

See:

Who's the boss? White House recommends physicians join hospitals, large groups 

Your comments

	Picking a team: The hospital or private practice?
	# 1 of 2	September 19, 2010 08:41 (EDT)
	Melissa	Please see the forum for ongoing discussion of this blog.
	# 2 of 2	November 3, 2011 05:07 (EDT)
	Chris	My apologies, I misread this form and thought that email meant email this article to someone, because I found this article very informative and am actually doing an essay on the effects of prrivate practice decline on doctor patient relationships.  So I apologize for the first comment, I thought I had to include a comment in the email to myself

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