By Bob Sweeney
May 11, 2020

Among the most disruptive changes in clinical practice over the last five years has been the shift toward physicians being employed as opposed to running their own practices.    This trend has been particularly widespread with younger docs.  According to the American Medical Association, over 70% of physicians under the age of 40 were employed in 2019.  To illustrate the extent of this trend, in 2019 the percentage of employed primary care physicians outnumbered those still independent.  Once we factor in the large contract companies in emergency medicine and other specialties that, while perhaps physician-owned, operate as employers, the balance shifts even more.

Among the factors that drove and still drive physicians into employment are:

  • The enormous debt burden undertaken by young physicians in acquiring the education and training, often ten or more years, that gains them entry into practice in the first place.
  • Changes in the role of women in society and the clinical work force
  • Rising demand for ever more bureaucratic participation in medical administration —documentation, insurance issues and defenses, and other administrative duties not associated with seeing patients
  • Costs of ancillary and other services, with associated pressure to adopt new technology without a full appreciation for how systems work and their side effects.

One might expect that the most pressing aspects of this trend would be financial, but that is not the only, nor necessarily, the most important disruption.  There is evidence, both anecdotal and statistical, that interference in the actual practice of medicine is even more of an issue.  For example, my colleague Hassan A. Tehteh, MD, an expert on physician burnout, has written profusely over the last five years on this topic.   When hospital administrators direct the selection of technology, the time “allocated” for seeing patients, and even care protocols, physicians become emotionally discouraged and disengaged.   Most physicians go into medicine in order to treat patients, not serve the whims of corporate managers.  But corporations, non-profit or otherwise, inevitably operate to optimize financial objectives.  There is an inherent conflict of agendas that is causing a dramatic increase in physician burnout and turnover. 

Ironically, the Covid-19 pandemic has changed the dynamics and the potential balance of power, particularly for primary care physicians.   The failing economics of office-based practice drove these specialties into selling out to hospitals and contract groups in the first place.   However, telemedicine presents a path back to fiscal solvency and practice control through cost reduction and distributed care.   The rush to telemedicine in the face of contagion not only favors the independent physician; it also gives docs frustrated by hospital intrusion into the mode and substance of care an alternative to remaining in an unsatisfying and stressful environment.   There are trends afoot across the United States in cities such as Boston, San Francisco and Memphis where physicians are buying or opting their way out of employment relationships and returning to independent practice.  By taking advantage of service and communication networks, they can leverage the power of scaling to purchase the supporting services required to enter practice at substantially less expense than they faced as sole players five years ago. 

As with the other factors breeding disenfranchised physicians, practicing docs are finding ways to regain autonomy and restore the physician-patient relationship to primacy in medicine.

Bob Sweeney, Principal & Managing Partner
Global Health Impact Network