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Employment: Is Security Really Worth It?

Some refugees from employment have been contacting OmniMD, a Tarrytown, New York-based company that helps set up information technology, because they need IT when they reopen private practices.

“These doctors have just had it,” reports OmniMD CEO Divan Dave. “They feel that they were just another employee. They tell me, ‘The hospital has put me on a treadmill, and the incline keeps going up.’”

A Tidal Wave of Newly Employed Doctors

Physicians have been flooding into employment. Studies within the past few years have shown that about one half of all physicians are employed, and one of the newest surveys,[1] by Medscape, showed that fully 63% of doctors were employed.

Employed doctors seek security—a steady salary, a predictable schedule, and not having to manage the business side of medicine. But for many, it’s a Faustian bargain, to some extent. In return for security, they give up some control. They may have to see a certain number of patients, consult clinical guidelines, have their practice patterns monitored, and be unable to hire their own staff.

What effect do these new constraints have on a profession that has always prided itself on independence? Will the employment trend forever change the face of medicine?

Formerly Employed Doctors Pinpoint Concerns

Most employed physicians are generally happy with their work, but a number of them are bailing out and returning to independent practice, and they have some sobering stories to tell.

Some refugees from employment have been contacting OmniMD, a Tarrytown, New York-based company that helps set up information technology, because they need IT when they reopen private practices.

“These doctors have just had it,” reports OmniMD CEO Divan Dave. “They feel that they were just another employee. They tell me, ‘The hospital has put me on a treadmill, and the incline keeps going up.’”

Similar concerns were voiced by a cardiologist who was employed by two large health systems in the South. He asked not to be identified because he had critical things to say about both organizations, and he will still need to deal with them now that he is setting up a private practice in the community. Following are some of the experiences he had with one or the other system.

Rush, Rush, Rush Through Patients

The unnamed cardiologist says he was forced to maintain an overbooked schedule. He was scheduled to see up to 26 patients in a day, which amounted to about 7 or 8 minutes of face time per patient. To give his patients the care they needed, “I would be at least 1 hour behind on a regular basis,” he said, and keeping up meant “working at a feverish pace.” He asked his office manager to reduce the number of scheduled patients, but she said, “That’s what they mandated downtown.”

He was sent report cards showing the revenue he was generating for the system. The report cards showed the number of relative value units (RVUs) he logged from seeing patients and performing diagnostic studies. He was compared with colleagues; high-scorers were awarded a bonus, but the cardiologist never received one because he refused to change his practice patterns.

He says he was prodded to order more expensive tests. A physician-administrator reviewing his performance metrics suggested, “Perhaps you’re missing out on opportunities to order more tests.” Some colleagues were earning bonuses by ordering a greater number of more expensive cardiology tests.

The cardiologist wasn’t rewarded for improving outcomes. His clinical data showed that his patients had better outcomes than those of most of his colleagues’, but that didn’t seem to matter in reviews of his work. He recalls his cardiology chief telling him, “The way you practice medicine may be the future, but right now it isn’t.”

The cardiologist says that leaving employment and starting a new practice was daunting at first, but after some planning, he believes it will be successful. Although it may take a year or two to break even, he expects to be professionally happy for the first time in years. “I won’t have to answer to anyone except my patients,” he said.

In a 2014 Medscape survey,[2] respondents mirrored many of these concerns. Asked what they liked least about their jobs, employed physicians listed, in order of preference, limited influence in decision-making, more limited income potential, too many rules, less control over work or schedule, and being “bossed around” by management. In addition, unhappy physicians are prevented from leaving by restrictive covenants, which stipulate that they can’t practice in the same area after they go.

Bernetta Avery, MD, a pediatrician who was employed by a hospital in San Francisco and at a large practice near Portland, Oregon, did not have as serious problems with her employers but still felt a distinct loss of control. Of note, she said she was about as unhappy with the group practice as with the hospital. Both were demanding what she calls “factory medicine”—putting an excessive emphasis on productivity. When physicians were evaluated, “a common metric of success was how many patients you can see in a short period of time,” she said.

“When you’re an employed physician, somebody else designs, implements, and controls the environment in which you practice,” Dr Avery says. She faced extra hurdles when she opted for care that didn’t follow the institution’s practice guidelines.

Good Things About Being Employed

Not all of her experiences as an employee, however, were disappointing. Dr Avery still raves about working at the Children’s Hospital of Philadelphia at the start of her career. “Everyone was pulling for the good of the whole,” she recalls. “There was an expectation that you work to be at the top of your game, and the organization meets you to support that goal.”

Like the cardiologist, Dr Avery left employment and is now starting her own practice. “It’s going to be demanding,” she said, “but it’s easier to enjoy hard work when you have the ability to influence and shape your practice.” She plans to have longer patient visits.

When Carolyn DeSalvo, MD, was a hospital employee, she didn’t feel under pressure to be more productive and didn’t see her pay drop, but she did feel a loss of control. Working as an obstetrician/gynecologist at a hospital in Kansas, she could not get a raise for her nurse because she was already at the top of the hospital’s pay scale. Also, “it was not a nimble organization that responded quickly to needs,” she recalls. She is moving to Washington State to start her own practice.

Dr Avery and Dr DeSalvo are both clients of Mary Pat Whaley, a consultant in Durham, North Carolina, who has been helping formerly employed physicians return to independent practice. Whaley says she has been getting several calls a week from doctors leaving employment. She has been helping clients outsource many features of their practices, such as billing and staffing, so they can keep expenses low and focus on clinical care.

Are Physicians Becoming Interchangeable?

In some respects, the employment trend promotes the view that many doctors are interchangeable, says Fred Davis, MD, president of ProCare Systems, a practice management company involved with pain management in Grand Rapids, Michigan.

Dr Davis says the expectation behind physician employment is that any physician can produce superior outcomes by using evidence-based clinical standards and monitoring of clinical outcomes.

“The belief is that you can create high quality within a properly managed structure, even with a less sophisticated workforce,” he said. “This is what Toyota has done, and it has been very successful, but the jury is still out on whether it works in healthcare.”

One chief casualty of this way of thinking, Dr Davis says, is “the marquee physician” who doesn’t want to work on a team. “These physicians are very outspoken and are not the best bet for employment,” he says. But many of them are innovators who were responsible for major breakthroughs in medicine, and stifling them is a loss for healthcare, he said.

Dr Davis concedes, however, that organizing physicians and holding them to precise standards has been adopted not just by hospitals but also by many physician-led organizations concerned about quality, such as Mayo Clinic and the Cleveland Clinic.

One strong champion of this approach is the Permanente Medical Group, the largest group practice in the country. Some 8000 physicians, most of them partners who share in the organization’s income, staff Kaiser hospitals in California and several other states.

The Importance of Being a Team Player

Robert Pearl, MD, executive director and CEO of Permanente, doesn’t use the word “interchangeable” to describe his doctors. He does note that they are team players. “The best care is when a team of high-quality physicians work together as one on behalf of their patients,” he says. “‘Me-first’ people don’t fit well into a team. No one is so exceptional that they become more important than their colleagues.”

Permanente physicians base their care on guidelines created by the group’s Care Management Institute, but Dr Pearl says they generally have the freedom to choose whether or not to follow them, and they constantly debate with each other how the guidelines should be used.

Also like employed physicians, they work a limited number of hours—”We don’t want people to work 100 hours a week,” Dr Pearl says—and get generous vacations. This is possible because “other doctors fill in for you when you’re off work,” he says. An associate physician at Southern California Permanente Medical Group gets a maximum of 28 vacation days a year after 10 years of service.[3] The physicians “need time to relax and rejuvenate,” Dr Pearl says.

The benefits are a big draw. Dr Pearl says Permanente gets 10 applicants for every physician job opening, and Kaiser itself has been ranked as one of the “50 Happiest Companies” for 3 years in a row by CareerBliss,[4] an Internet employment site, on the basis of surveys of employees at large companies.

Many health systems use Permanente’s approach with employed physicians, but Dr Pearl sees a big difference. “When a hospital acquires your practice, it is using you to further its goals,” he said. “You really become a hired hand. Your role is to drive up volume and generate revenue toward their bottom line.”

Most Young Doctors Want to Be Employed

Although some employed physicians are clearly unhappy, the fact of the matter is that most of them feel quite content. The 2014 Medscape survey found that 73% of employed physicians were satisfied with their job—not much different from the 74% figure for self-employed physicians.

However, employed physicians who had previously been independent had considerably bleaker views in the survey. Less than one half of them said they were happier, and one quarter of them were less happy.

This subset of physicians tends to be older, and older physicians are much less likely to seek employment in the first place. In the Medscape survey, just 12% of physicians aged 40 years or older were employed, compared with a whopping 70% of physicians under age 40.

“Younger physicians have a higher threshold of tolerance for employment,” says Michael Hanak, MD, a 35-year-old family physician who is chair of the Young Physicians Section of the American Medical Association (AMA-YPS). “They’re generally more comfortable with using clinical guidelines, provided that they’re evidence-based.”

Dr Hanak himself is employed. He works at Rush University Medical Center in Chicago, which runs two hospitals, a medical school, and a practice with more than 500 employed physicians.

Changes in outlook and training seem to be driving younger doctors’ preference for employment. Dr Pearl, the Permanente CEO, has observed[5] that young physicians are part of the millennial generation, born between the early 1980s and the early 2000s, who are said to value their time away from work and operating in teams. “Younger generations of doctors prefer the greater work/life balance and predictability that larger employers offer,” he wrote.

Dr Hanak thinks that experiences in medical school and training gave his cohort a taste for employment. He said medical schools now teach students to work in teams and use clinical metrics. Then in training, they tend to work in large institutions, where they earn a salary and are expected to “play by the rules,” just like employed physicians must do, he said.

Mark Meyer, MD, associate dean for student affairs at the University of Kansas School of Medicine, generally agrees with this assessment. At his school, “the curriculum promotes the team approach, use of data, and evidence-based medicine,” he said, but he added that his institution still provides exposure to private practice in fourth-year clerkships.

No Rush Toward Solo Practice

Ted Epperly, MD, president and CEO of the Family Medicine Residency of Idaho, in Boise, which operates seven residency and fellowship programs, reports that only a couple of graduates in the past decade have started solo practices. Although quite a few still join small practices, ” far and away, they’re joining larger groups and hospital systems,” he said. “They want to focus on the profession of medicine, not the business of medicine.”

Indeed, when last year’s Medscape survey asked employed physicians what they liked most about employment, 58% cited “not having to deal with the business side of running a practice” higher than any other listed factor. They also listed not having to deal with insurers and billing and the possibility of a guaranteed income and even cash flow.

Young physicians are aware of the pitfalls of employment, but “they feel they can change policy by working within the system, and if that isn’t successful, they can move on,” Dr Epperly said. To make it easier to move on, many of them are demanding that hospitals remove restrictive covenants from their contracts, he said.

This willingness to move around has become a feature of the entire medical profession—not just the young doctors, says Dr Davis, the Michigan practice management advisor. As opportunities for physicians grow, “it’s easier to move around,” he said. “Doctors have become nomadic.”

The prospect that unhappy doctors could just pick up and leave is a good incentive for hospitals to treat them well. Press Ganey, the purveyor of patient satisfaction questionnaires, also sells a “Physician Voice” questionnaire to help organizations measure physician morale as well as their “alignment” to institutional goals. The company reports[6] that almost one half of the US News Honor Roll Hospitals use the survey.

A Generation Gap Is Opening

The wide gap in interest in employment between older and younger physicians leads to some friction.

Hal Scherz, MD, a pediatric urologist in Atlanta, thinks physician employment is bad for the profession. “When you’re working for an institution, it’s going to tell you how to practice,” he says. “Middle managers are looking at the number of patients you see, watching your schedule.”

He has hosted urology residents in his practice for almost 30 years, and his impression is that young doctors seek employment because they don’t want to work hard. “The current residents generally want to be employed, and they don’t seem to have the same work ethic as older physicians,” he said. He thinks young physicians have been influenced by work-hours limits for all residency programs, instituted in 2003.

Dr Scherz, who was one of the first members of his group, which now includes 41 doctors, says he’s disappointed that young doctors in the practice don’t seem interested in attending meetings about the business side of the practice. “They’re content to let others do the managing,” he said.

These generational differences also arise within families. When William Alsop, MD, a recently retired gastroenterologist from Salina, Kansas, exited training more than 30 years ago, private practice was simply not an option. He established a solo practice and added a couple of partners over the years.

“I liked being an independent physician because you’re not employed by a system and not beholden to anyone but yourself,” Dr Alsop said. He worked long hours, starting the day at 7 AM, coming home for dinner, and then going back to work until after 11 PM, he says. When his son Ben was a boy, he asked whether Dad slept at the hospital. But Ben admired his father’s work and paid him the ultimate compliment by opting for a career in medicine, even choosing his father’s specialty.

The younger Alsop, however, won’t be following his father’s lead into a small practice. “I don’t want to have to worry about things like overhead and keeping the lights on,” Ben Alsop, MD, said. “They’re an unnecessary headache.” After he graduates from his fellowship in June, he will be working as an employee at a Veterans Administration (VA) hospital.

ISM Project Challenge Covered in Subah Savera News on 03.07.2015

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ISM Project Challenge 2015 Press Release Covered in Gujarati Media on 02.07.2015

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Krutika Thakkar from Vadodara Institute of Engineering emerged as the Champion of ISM Project Challenge 2015

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ISM Inc Yoga Day Celebration Coverage in Divya Bhaskar Ahmedabad on 22.06.2015

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International Yoga Day Press Release in News Media on 21-06-2015

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TV9 News Channel interview with ISM CEO – Divan Dave on International Yoga Day

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Integrated Systems Management Inc. International Yoga Day Celebration

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Press Release Published in Times of India on 6-June-2015

ISM project challenge 2015 extends date for entries -

Chitra Unnithan, TNN | Jun 6, 2015, 07.05PM IST

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AHMEDABAD: ISM has decided to extend the project submission date till 15th June, 2015 for its project challenge. Students who have missed this opportunity to participate in the challenge can submit the final year project by 15th June, 2015.

ISM is encouraging IT students in Gujarat with high potential to take part in this one of its kind event where they can be recognized for their innovations in the IT arena.

Rajesh Yadav, Director-India Operations and HR, said, “We are pleased with the kind of response we have received and are continuing to receive from the IT students across Gujarat. Hence we have decided to extend the deadline to submit the projects and we are welcoming new entries. Keeping in line with our company’s philosophy to motivate and nurture young talent we have decided to give fair chance to every single final year IT student across Gujarat.”