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Independent to Employed—And Back Again

In one corner, you have a pile of studies, including this one, showing that physicians employed by a hospital or group are the wave of the future. About 60 percent of family physicians are working for either hospitals or physician groups, the American Academy of Family Physicians reported back in 2013. Hospital and health system employment of physicians increased by more than 50 percent during the past three years.

After years of crazy hours, unpredictable income, and forests of regulatory and payer paperwork, who wouldn’t want the comfort of a set schedule and a steady paycheck? For starters, consider the physicians in the other corner who have been there and now say, “Not so fast.”

Some physicians find employment in group practice to be untenable.

These are practitioners who were independent, went to work as employed physicians, and then left. This isn’t how the story is supposed to go. What happened to happily ever after? Is private practice really going away?

The transition of physicians from private practice to hospital employment can be arduous. As in other career fields, sometimes an employment situation is just a bad fit, for any number of reasons. The biggest challenge for physicians is the perceived loss of autonomy they experience when they join a practice as an employee.

The Happy MD website identifies three situations where that lack of autonomy might spur employed practitioners to leave:

Toxic culture: The hospital or physician group that cuts the paychecks might have no conscious culture or code of honor that binds its workforce together, or the hospital may not hold the group to a single high standard of professionalism. Most groups simply continue the culture of residency programs, as Dike Drummond wrote on Happy MD.

“Competition, everyone working as hard as they can on their own personal gerbil wheel, no acknowledgement of humanity, never show signs of weakness, get out of the office as fast as you can, the biggest producer gets their way,” he stated.

Employed physicians might even be targeted if their standards or requirements get in the way of hospitals’ agendas.

Independent practice
Lack of input in decision making: Independent physicians accustomed to a high level of autonomy might feel they have no voice in an employment scenario. The group should seek out and respect members’ opinions, but employed doctors may think their concerns are unheard or unappreciated, even in situations where patients are being put at risk.

Toxic supervisors: Leaders, whether physicians or non-physicians, who lack emotional intelligence, communication skills, or strategic vision can make an employment situation difficult to sustain. Physicians who are accustomed to solving problems or making their own decisions might not have these opportunities in bureaucratic settings.

Another potential deal breaker for employed physicians could be technological. The system they join will have its own EHR, practice management processes, and coding and billing practices. If these new systems are cumbersome, onerous to learn, or unintuitive to use, that can be an incentive for the physician to leave when his or her contract is up.

It’s worth noting that more newly minted practitioners are entering the workforce as employed physicians, having never known the rewards and challenges of independent practice. Recent surveys have found that between one-half and two-thirds of current physician practice opportunities or searches are for employed positions. Nevertheless, these physicians are also leaving their “starter job” employers.

When exiting a group employment setting, exercise care.

Steps toward the exit
The AMA has created guidance to help physicians avoid physician-unfriendly contracts, conflicts of interest, and ethical quandaries. As the trend toward employed models increases, physicians are reporting difficulties in treatment and referral interference, vague contract language, compensation-associated performance metrics, and unrealistic productivity expectations. Some key recommendations are in AMA’s “Principles for Physician Employment.”

If the employed life isn’t working for you, there are a couple of things to keep in mind.

What tail coverage, if any, is in the employment contract? Most physicians will want their former employer to pay for extended reporting when they leave a practice. The obligation to pay tail coverage, if there is one, must be clearly spelled out in the employment contract. Often, the employer’s obligation to pay is conditioned on the employee’s fulfillment of certain conditions, such as giving adequate notice of intent to depart. Physicians who intend to leave should not let their tail coverage lapse because of a dispute over payment.

When physicians leave a difficult employment situation, they may be tempted to cut all ties and make it difficult for that practice to contact them, employing such practices as using a post office box or a telephone number that goes directly to an answering service. But even when you’re leaving a position under less-than-ideal circumstances, you should leave adequate forwarding information. Patients or payers may need to contact you, especially where audits and adjustments are concerned. If your former employer doesn’t know where you are, there will be complaints to the medical board and those complaints will find you.

The bottom line: It might be a major trend in care delivery, but employment isn’t the best answer for all physicians. If you’ve tried it and it’s not for you, head for the exit with care.

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