Day 3: For young doctors, hospital paycheck trumps solo practice

12/30/2013 11:24 PM

01/02/2014 11:49 AM

For newly trained physicians Kristin and Brian Gillenwater, mornings are a rush.

They grab a bite of breakfast. They get Henry, their 1-year-old, ready for day care, then drive off in different directions for a busy day seeing patients.

The Gillenwaters don’t head to their own practices.

An independent practice doesn’t hold the same attraction for them as it did for earlier generations of physicians. Independent practice means managing a business and working long, unpredictable hours for what’s become an increasingly less certain income.

Instead, growing numbers of doctors of the millennial generation like the Gillenwaters are choosing employment, most often by hospitals.

Millennial physicians are entering the job market at a time when hospitals nationwide have been hiring thousands of doctors and snapping up hundreds of practices of older, independent doctors.

Hospitals want doctors in their employ to secure — or expand — their share of a rapidly changing health care marketplace.

But it’s the career inclinations of young doctors, as much as the economic ambitions of hospitals, that may be dooming the iconic small, independent doctor’s practice to a marginal role in medicine’s future. Some observers say we may already have reached the tipping point where doctors who work for systems of hospitals and clinics will become the rule, rather than the exception.

Hospital employment was the No. 1 career choice among medical residents in their final year of training, a 2011 survey by physician recruitment firm Merritt Hawkins found. Only 1 percent of these new doctors said they wanted their own solo practices.

“There’s something very appealing about being an employee and having someone else pay the light bill,” Kristin Gillenwater said.

“And if you run your own practice, how do you take maternity leave? I really didn’t want to delay having a family.”

Gillenwater is the chief resident in internal medicine at the University of Missouri-Kansas City School of Medicine. She plans to work for a hospital or medical school after she completes her training next year at Truman Medical Center.

Her husband, Brian, finished his residency in family medicine and started work this summer as an employee of an outpatient clinic operated by Liberty Hospital.

“I’m working basically a 9-to-5 job,” Brian Gillenwater said. “I could choose to work more, but I get to spend the time at home.”

That means time with his family, time to watch Sunday football.

“How much can you work before you burn out? I love medicine too much to let that happen.”

Changing the game

Two years ago, anesthesiologist Karen Sibert stirred up the medical community with a tetchy op-ed in The New York Times in which she questioned the commitment of young doctors who wanted limited work hours.

“Along the way, I’ve worked full days and many nights, and brought a lot of very sick patients through long, difficult operations,” she wrote. “Medicine shouldn’t be a part-time interest to be set aside if it becomes inconvenient; it deserves to be a life’s work.”

Surveys suggest that members of the millennial generation — born from the early 1980s through the early 2000s — are largely unconvinced that career advancement should take priority over their personal lives.

And for millennial doctors, dramatic changes in their profession have given them added reason for working for hospitals.

Medicine is no longer a male-dominated profession. Since the mid-2000s, women have made up close to half of all medical school graduates. And increasingly, young doctors like the Gillenwaters are marrying other doctors. Accommodating each other’s demanding careers makes flexible schedules, child leave and part-time work a priority. That’s a lot easier when you’re not responsible for running your own practice.

How doctors are paid is changing in ways that make it less rewarding to be a workaholic. Government programs like Medicare and commercial insurance companies have begun placing more emphasis on the quality of the care that doctors provide and less on the numbers of procedures they do. In the future, working long hours may not be worth the effort.

Many older doctors are sympathetic to the desire of millennials for greater balance between their work and personal lives.

“I think they are trying to adapt to a system that wasn’t sane to begin with,” said Mark Meyer, associate dean for student affairs at the University of Kansas School of Medicine. “They want greater flexibility to practice medicine, raise a family, serve society.”

In the past, it was the norm to run your own practice, Meyer said.

“You were defined by your practice, by being a physician. Now you’re a diversified individual. I’d argue that translates into better physicians, because they’re more well-rounded, more in touch with the communities they serve.”

William Alsop graduated from medical school in 1977. When his son, Ben, was planning to go to medical school, the Salina, Kan., gastroenterologist gave him this advice: “Don’t marry another doctor, because you’ll never see each other.

“But that was looking at it from 1970s standards. I was wrong. The attitudes then, we were more like cowboys. ... There were sayings like ‘Medicine is a hard mistress.’ 

Alsop has always been in an independent practice. For the first 20 years of his career he regularly worked 16-hour days. Now in his 60s, he still averages eight to 10 hours per day.

“I worked hard, and I worked long, and that takes its toll on you,” Alsop said.

“People’s attitudes about what it should be like for them are different. I do get it. Young doctors want more control of their life.”

Ben Alsop, who is training in gastroenterology at KU, did end up married to a doctor. She’s a surgical resident at KU.

Ben Alsop expects that both he and his wife will end up as employees, if only because it’s tough now for independent doctors to compete against practices backed by large, wealthy hospitals.

“It’s a huge business — the facilities, the technology, how comfortable the rooms are. It’s hard for independent practices to stay afloat with the big guys having advertising and streamlined production.”

Costs, complications

It’s not just the competition from hospitals that is making it hard to start an independent practice. New doctors are coming out of training programs with record levels of student loan debt.

The average medical school graduate in 2013 owed $175,000. That’s up from $115,000 in 2004. Even accounting for inflation, medical student debt has more than doubled in the past two decades.

On top of that are the start-up costs of a doctor’s office — rent, payroll, insurance, furniture, equipment, latex gloves, cotton balls and tongue depressors. Add to that computers and software for electronic health records that can cost more than $30,000 for just one physician.

All told, these expenses can run as high as $150,000 for a solo practice, compared to about $100,000 a decade ago. That means taking on more debt.

Just as daunting is the welter of rules and regulations for billing, patient privacy, office laboratories, prescribing drugs, and on and on.

“I think 20 years ago it was much simpler to be the owner of a small practice,” said Betty Drees, dean of UMKC’s medical school. “You really have to be driven by that passion to be a physician to come in at this time of economic uncertainty.”

Reid Waldman, a third-year medical student at UMKC, expects to be $180,000 in debt by the time he graduates. He’d like to run his own practice but doesn’t think it’s likely. He’s looking at loan repayments of about $1,000 per month.

“I really do like the business component of medicine. But economically, it doesn’t make much sense,” Waldman said. “When you have all the overhead, a private practice won’t be able to make that back as a hospital can.”

He expects almost all his classmates will end up working for hospitals and preferring it to private practice.

“It’s nice to just walk into the hospital and just get a list of patients to see,” Waldman said. “Frankly, I don’t think a lot of people are interested in the business end.”

Many new doctors finish their training with little of the expertise necessary to run a practice. In the 2011 Merritt Hawkins survey, 48 percent of graduating residents said they were unprepared to handle the business side of their career. Only 9 percent felt “very prepared.”

“They don’t know how to run a business. They’re scared to,” said Daniel Smith, a resident in anesthesiology at UMKC. “We don’t get any major training in this. We’re really not taught to bill. We’re really not taught the rules.”

Smith, who plans to go into private practice, is that rare doctor who majored in business in college. When he knew he wanted to go into medicine, he asked doctors what they


get in medical school. It was business training.

Smith attends the practice management classes that UMKC offers, but many residents skip them, he said.

“They’re idealistic about what makes a good doctor. They don’t worry about costs, reimbursements.”

And with so much medicine to learn, they may not have time to give business much thought, Smith said.

“The problem with medicine today is that we’ve gotten so super-specialized. It’s almost that residency programs are pushing us toward hospital employment.”

Working as a team

If new doctors are feeling they’re being pushed into hospital jobs, at least they’re being better prepared for life as an employee than in years past.

The days of the imperious independent physician who gives commands is either gone or rapidly disappearing. Now doctors are expected to play well with others.

“I think in the past, physicians could get away with a lot of unprofessional behavior. There was a patriarchal approach to things,” said Jill Moormeier, associate dean for graduate medical education at UMKC.

“There’s an expectation now that they have to work as part of a team,” Moormeier said. “A physician can’t do it all. The residents realize that.”

Teamwork among health care professionals is essential to the new models of care being tested as ways to hold down costs and improve quality.

Doctors hand off their patients to nurses, dietitians, social workers and therapists to provide more comprehensive care. The goal: patients stay healthier and don’t run up as many big bills.

Even a small doctor’s office can assemble a health care team. But hospitals have more resources. They’ve been hiring doctors and buying up their medical practices to create large-scale teams that will position them to take full advantage of new payment systems.

Medical schools started emphasizing teamwork among doctors and other health care professionals about five years ago, said Carol Aschenbrener, chief medical education officer of the Association of American Medical Colleges.

“There’s been a growing recognition that we can’t do what we need to do to reform health care delivery without more interprofessional collaboration,” Aschenbrener said.

“For doctors to be part of a team, and not always the leader, you must begin early in professional school, before their professional identity is set.”

At UMKC and many other medical schools, residents make hospital rounds accompanied by nurses, social workers and pharmacists to see patients. KU medical students train side by side with nursing students and others.

The students come together at KU Medical Center to go through scenarios at a simulation lab where realistic mannequins substitute for patients in mock-ups of hospital rooms.

During one recent simulation, student doctors, nurses and pharmacists huddled over an infant who was suffering a seizure. At a debriefing afterward, faculty members Mitzi Scotten, a physician, and Mary Meyer, a nurse, gently commented on how well the students shared the work.

“It used to be a caste system. Physicians were the supreme commanders of the universe,” Scotten said later.

“We’re training pit crews now,” Meyer added.

“Things are moving faster, faster than I would have predicted,” Aschenbrener said. “Students really like it. Interprofessional cooperation is another kind of diversity, seeing things through other people’s eyes. Younger people take to that easily.”

Like other students at UMKC’s medical school, Waldman spent two weeks in the “hospital team experience” learning what life is like for employees who aren’t doctors.

Working in central supply and environmental services at Research Medical Center, Waldman loaded gloves and scrubs on a cart that he pushed through the hospital making deliveries. He buffed floors in patient rooms, cleaned bathrooms and the emergency room, mopped up blood and other bodily fluids.

“It really gives you an appreciation that there’s a lot of components to making a hospital run smoothly,” he said. “There’s really no place for arrogance in health care.”


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