Thursday, August 28, 2014

The solo general surgeon is a dying breed. What is next?

This is a guest post by Dr. Paul A. Ruggieri, a general surgeon in Fall River, MA and author of a new book “The Cost of Cutting: A Surgeon Reveals the Truth Behind a Multibillion-Dollar Industry.”

A potential casualty of employment in a hospital system may be the ability to openly disagree with the organization. Will surgeons, as highly paid employees, be confident enough to speak up against hospital policies affecting patient care without worrying about corporate retaliation? Will employed surgeons be able to speak out against hospital cost-cutting measures that infringe on patient care without being labeled whistleblowers or troublemakers? Can they voice their displeasure without worrying about the security of their job? If you are branded “not a team player,” referrals may dry up. Or, you may suddenly be “asked” to take more emergency room call. You may also be asked to travel farther to see patients and generate surgical business in another town. You may be replaced. You could end up as a surgeon without a practice. If let go, you may discover that the clause in your contract prohibiting you from practicing within the area drives you out of town.

Will employed surgeons be able to openly highlight waste and fraud without fear of losing their jobs? As highly paid employees, surgeons risk much if they criticize the organization that employs them, even when the intent is improved patient care. Knowing the economic stakes of speaking against the corporate team, I suspect many may choose to be silent.

Now that more surgeons are giving up their independence and joining the ranks of the employed, will they have the ability to unionize? Historically, surgeons have been an extremely independent breed of physician, perhaps too independent for their own good. For whatever reasons—ego, stubbornness, a view of themselves as well above the average working stiff, money, competitive juices—surgeons have never been able to use their local muscle to influence hospital behavior. Instead of being able to unionize freely decades ago, surgeons may now be forced to in order to survive.

Will unionized surgeons be given collective bargaining rights when negotiating with their employers? Will surgeons be able to strike if they feel the hospital systems they work for are not negotiating salaries or working conditions in good faith? Can you see it now, a Teamster walking the picket line in solidarity with a white-coated surgeon over improving health benefits? Will there be appeal boards to contest unfair firings? As employees, will surgeons be able to negotiate for vacations, sick time, or family leave?

The writing is on the wall for all surgeons, including me. The era of the independent surgeon is drawing to a close. More and more patients will be cared for by surgeons whose economic and surgical lives are directly influenced by the corporate entities that employ them. What, if any, impact will this dramatic shift in the surgeon’s professional world have on the access and quality of surgery practiced in the future? It remains to be seen, but there is a reason the American Medical Association (AMA) specifically addressed this shift in 2012 with new guidelines for physicians selling their practices. Tellingly, the AMA stated that “patients should be told whenever a hospital provides financial incentives that encourage, discourage, or restrict referrals or treatment options.” The AMA statement continued: “Physicians should always make treatment and referral decisions based on the interests of their patients.” Isn’t this how physicians and surgeons already practice, and have for hundreds of years? Or is it?

As a patient, should you know who your surgeon works for before agreeing to an operation? If you’re interested in a dinosaur’s perspective, the answer is “Yes!”

What do you think about Dr. Ruggieri's view of the future?


artiger said...

Just based on the above excerpt, I'd say it's an overly cynical view. Physician employment is not an issue unique to surgeons, so I don't see very much new about this. As for being pushed around by hospital systems, I can only say that careful review of a contract before signing is essential. If a hospital won't budge on something important, go somewhere else. The supply of surgeons is contracting. Always remember that in negotiations.

Full disclosure, I am an employed solo surgeon.

Paul Ruggieri MD said...

Sugeon employment is not a unique issue. However, independent practices are coming under increasing pressure because primary care control the referrals. More and more primary physicians are becoming employed and getting pressure to retain their patients within the system. As an independent surgeon, my referrals dry up when a hospital system hires its own surgeons, despite years of quality outcomes. This is what is unique to today's practice settings.

Paul Ruggieri MD
Yes, I agree careful review of a contract is essential. Yet, once they have you settled in, demands on your job description can change overnight. The reality of going somewhere else is not as simple as that statement makes it.

RobertL39 said...

Perhaps a more sanguine view is to look at the Kaiser system. My institution (non-Kaiser) hires only anesthesiologists, pathologists and ER docs; surgeons and others are independents. Hearing much grumbling in all quarters, I began to wonder if there were any hospitals where docs were happy with their work situation. Parenthetically, our hospital did a 'satisfaction survey' of the medical staff every year. A consistent finding was that the docs who used the hospital the most liked it the least! After a statistically inadequate survey of other surgeons, I determined that the doctors employed by the large multi-specialty clinic were generally happy with their situation, whereas the solo or even single-specialty group surgeons were not. Those folks I surveyed who knew docs who worked at Kaiser unanimously said that the Kaiser docs were quite happy with their situation. I wonder if the same findings would hold on the other coast. How do docs at, for example, Geisinger Health System feel? I suspect that the key is having enough clout on the physician side, whether it's an exclusive hospital-physician group arrangement like Kaiser or a dominant but not exclusive multi-specialty group-hospital linkage. The lone dinosaur holds little sway over events, and the ability of individual dinosaurs to work cohesively toward an end has been time-tested and found to be poor. See the late Arnold Relman's "A Second Opinion". Dinosaurs, prepare to evolve, continue to be frustrated or retire.

peter said...

We became hospital employees about 8 years ago. Is it the best model for our patients? I'm not sure, but without that move it's likely none of us would still be in town. It simply wasn't financially viable to be a private practice group anymore.

In a moderate sized city (about 90,000) in a largely rural/agriculture region, we still hold a fair amount of leverage with our employers simply because of the difficulty they would have in replacing us. There just aren't many people coming out of residency who want to do what we do (traditional non-orthopedic non-thoracic general surgery without subspecialization) or who are willing to live in a smaller population region. It's a power we try to use for good, not evil, and has probably allowed us to be more vocal in addressing medical staff and hospital issues than might otherwise be the case.

Ultimately, our increasing scarcity is our best leverage in dealing with employers. Admittedly, this would be less so for surgeons in larger cities or who are unwilling to pull up stakes if things go south. Again, employment by a hospital may not always be the best situation for the patient due to potential conflicts of interest, but at the end of the day it's better for the patient to have a surgeon in such an arrangement than no surgeon at all.

Skeptical Scalpel said...

Robert and Peter, thanks for the excellent comments. Surgeons will have to adapt.

Josh said...

A few comments: 1) Physicians can be employees of private practice groups as well as large healthcare entities, in which cases all of the described limitations apply as well, so its not just a David v. Goliath situation. 2) It is not an absolute truth that employed physicians have less of a voice or less capacity to influence change. In some cases, a physician recognized to be a good provider and local leader can effect tremendous positive change from within a system, perhaps even more so than the less-affiliated solo private practitioner. It all just depends. 3) As already stated, this is a terribly cynical view, so let me add my own hyper-cynical take. This trend is a long time in the making. Some marketplaces were made up entirely of solo private practitioners, working against each other as often as with each other, maximizing their overhead, fighting change, and grumbling about bureaucracy rather than just dealing with it. You would think the EMR revolution was on par with the December revolution. All of this was in the era of sky-high reimbursement, and with all of that money they built nothing (and in fact now want to sell their private island practices to surgeons of my generation). Is it little wonder that the wave of consolidation and employment is happening so quickly? On the contrary there are marketplaces where smart physicians worked together to create strong private practice groups, and those will be places where private practice will continue to thrive. But its hard for me to shed a tear for the endangered solo practitioner, who should have spent less attention on real estate investing and luxury vehicles and more attention on building something of value.

Anonymous said...

I'm part of a four person private practice group that does general/vascular surgery at a Level 2 trauma center. Most of the other doctors around here have joined the hospital except ortho ENT, and ob.
At our institution I see a steady stream of hospitalists, internists, family doctors, even urologists come and go. They are attracted by an intitial salary guarantee for a year or two, then when their salary goes down and they are on RVUs, they leave for another salary guarantee at another institution.
I too have wondered about becoming a "difficult" surgeon and "troublesome" when I insist on certain standards. I'm sure if I was employed by the hospital I'd have to be more circumspect in my criticisms.
Probably some hospitals treat their employed physicians well and appreciate their efforts to improve patient care.

FWIW our hospital was bought by a for-profit hospital that has record profits. I'm glad I'm not working "for the man", but maybe I will have to some day!

Skeptical Scalpel said...

Josh, I'm not sure when the er of sky high reimbursement you referred to existed unless you mean pre-1982 when Medicare rates were frozen. In general surgery, reimbursements haven't been sky high since then.

Anon, that's an interesting observation about docs coming and going. I think you will see more and more of that.

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