There are many factors in medicine these days that have pushed primary care practice to be mostly a salaried, employed-physician model as part of a large organization. Many of the old personal autonomy benefits have been lost. Rising overhead costs and lagging fee-for-service reimbursement have made it difficult for private practitioners to fund all the required elements of the new healthcare delivery team.
Additionally, there are heavy administrative burdens to achieve necessary certifications or just accomplish even simple care goals and also to follow required processes for optimal reimbursement. It has not all been bad, however. Emerging practice guidelines, desire for standardization and consistent quality of care, better control of lifestyle and personal time off are some of the more positive attributes to corporate employment. But this trend has also brought other important new challenges and realities to the primary care practice model that for centuries has been based on the principles of individual accomplishment, personal caring, and professional pride.
The changes in medical practice have also seemed to be based on generational differences in expectations about medicine as a career. Being a physician these days seems more of a job and not as much a consuming professional commitment as in the past. I have no doubt that our newest PCPs have at least as much caring and dedication to the cause of bettering our patients’ lives as ever, but, as a group, they also have stronger expectations about preserving more personal time for family and lifestyle needs. This is not a bad thing, either, as long as the needs of our patients still come first in how they are treated by the whole healthcare system.
So, how do we address the balance between delivering patient-based, compassionate, comprehensive healthcare and preserving our physicians’ lifestyle balance, professional satisfaction, and well-being? Given the current shortage of PCP’s, finding effective answers to this question is a critical challenge for effective healthcare transformation.
Clearly our new physician employment models often risk reinforcing the “me first” realignment of physician priorities as they often tie salary to volume of care, based on fee-for-service reimbursement models, rather than to quality. Likewise, employment contracts tend to be one-sided, employer-employee models, leaving employed physicians little opportunity or incentive for creativity in defining and improving how they do their jobs. These are shallow and short-sighted strategies as we go forward that can lead to the unintended consequences in today’s physician employment world, as evidenced by two telling observations.
One of the first unintended consequences of the newer employed physician model has been less sense of loyalty and connection and more tendency for younger PCP’s to switch jobs. Of course, this outcome is also promoted by the PCP shortage which allows almost unlimited alternative options for a physician currently disaffected by his or her current employment arrangement. This increased mobility has the very unfortunate effect of disrupting critically important continuity in the doctor-patient relationship around which trust, deeper caring, and improved outcomes are built.
Similarly, I see a blossoming, particularly among young physicians, of seeking “side gigs” and creating social media platforms. The effects of this and underlying reasons are harder to gauge. Whether they are seeking additional income opportunities or just ways to express their creativity, I think those energies would be better spent on their primary job if they were better incentivized to do so. It’s a missed opportunity for the healthcare system. We need to look at the level of reimbursement for our PCP’s and also the way we involve them in designing and “controlling” the way they deliver care to create the environment for them to devote their full focus and energies to their primary job and their patients.
If we are truly trying to build a patient-centered healthcare system, we must find answers to the “corporatization of medicine” that puts two central tenets at risk: connection and continuity between patients and their physician. It is therefore critical that we design our employment models for PCP’s to preserve and promote those principles.
The best models to do so will transparently outline the goals of the organization and challenges to be faced in meeting those goals.
Those models will provide guidance on how to practice, but also make the process open to input and continuous improvement ideas from all members, especially the physicians. By offering some real control of the work processes and more feedback about outcomes the result will be reduced burnout and improved job satisfaction.
Likewise, the best models will place employed physicians in skilled, multidimensional, well-trained teams that provide the full necessary support to address those challenges and allow physicians to use their top level training and skills for the bulk of their work, yet still have enough time for their personal lives. Those systems will improve patient outcomes (which should improve physician job satisfaction and dedication) and still control the work demands to allow a rewarding work/life balance. They must also find the funds to staff effectively at both the physician and support staff levels and reimburse the physicians at a full and fair level in view of their extensive training and professionalism. Similarly, supporting technology must always be designed to support the real work of the team and be user-friendly.
It seems clear to me that only the healthcare organizations that make a full financial and organizational commitmentto adjusting their PCP employment model in this way will be the ones with real success in achieving the triple aim by virtue of also addressing the “fourth aim”: physician satisfaction. The new healthcare paradigm demands it.