Interview with Christina Piron
Continued from “Evidence Mounts: Physicians Leaving Private Practice for Hospitals.”
Fergus: I’m preparing an article on the apparent shift of doctors away from private practice. As a senior medical student about to enter residency, you appear well situated to share an insight on this.
As you can see on page 11 of the American Medical Association Survey, the proportion of doctors under forty in institutional settings, compared with those over 55, is about twice as high. Is this simply the normal order of things, that as doctors get older they move into private practice? Or is this indicative of younger doctors favoring institutional settings? Other pieces of data, such as that from Merritt Hawkins, suggest new doctors favor hospital placement. Would you like to confirm this trend?
Christina: I do think that there is a growing number of physicians who are choosing to make their careers in institutional settings. There are a number of reasons that are contributing to this trend.
Part of the reason may be that there are an increasing number of people who choose to go on to fellowships to specialize after residency now compared to the past. Many of these people stay within larger institutions. It may be because of the built in referral network that these institutions have that you cannot get as easily out in the community.
Along those lines, the larger tertiary centers (like many of the university teaching hospitals) get the more interesting and challenging cases than out in the community – at least on a regular basis.
The other reasons they may choose to stay within the hospital setting are probably similar to why primary care physicians choose to do so, which I’ll talk about in a bit. As to why more people are specializing now, who knows. It could just be one of those trends. There are also more options for specialties now than in the past. New fellowships are cropping up every day.
Financially, specialists earn more money but still work the same number of hours. I hate to say it’s all about the money, but it’s definitely a factor. Reimbursement from insurance companies is better for the specialist than it is for the primary care.
Another reason contributing is the change in how hospitals and private offices are being run. Many private practitioners are no longer choosing to follow their patients while the patient’s are in the hospital. They leave the hospital management of the patient to hospitalist groups employed by the hospital. They may still stop by to check in on the patient, but it’s more a social call then anything else. This is definitely a newer trend.
Back in the day, more doctors would follow patients both as outpatients and inpatients. With the new push to electronic records, many of the older physicians find it easier to let these other docs manage their patients rather than learn the new system. Also, electronic systems may be different at each hospital in an area. This means that a community doctor would need to learn multiple systems and remember multiple passwords and logins just to round on his/her patients while they are in the hospital. It’s a lot of extra hassle without much of the reward. They would make more money by staying in the office seeing patients. They also probably get to go home at a more decent hour.
The hospitalists are well qualified and when a patient is really sick, are typically very good at updating the community doc about what’s going on so that continuity of care is held on to. Because of this trend though, hospitals are creating more hospitalist positions. The young, new doctors fresh out of residency are perfect to fill this position. We are not yet established and are used to working in the hospital setting. We are more comfortable working with the electronic records than our older, more experienced counterparts.
This trend is definitely real. There are now hospitalist fellowships that people can attend just to get more specialized training in how to deal with medicine specifically within the hospital setting. I think as time goes on, even less private community docs will continue to see patients while in the hospital. It is just imperative that as physicians we continue to communicate with each other, so that the community doc is well aware with what happened with the patient while in the hospital so that they can best care for their follow up needs.
There is also built in support and resources available by working in an institution. Granted there are a lot of politics and dealings with management, but everything is a trade off. You don’t have immediate access to the same labs and scans in the office setting. You also can’t call your specialist colleague to see the patient the same day. There is no radiology department to read your films right away. You have all of that in the hospital. I’ve heard some people mention that they like the schedule better as well. In some of the larger groups you can arrange for more flexibility in your schedule and time off. For example, you might work 1 week and be off the next. You’ll be very busy during that 1 week, working long hours, but the next week would be much lighter.
Fergus: Do you foresee consequences, positive or negative, from a shift towards larger, institutional settings?
Christina: Even though there is a growing number of people staying on with the larger institutions, I still believe that we will maintain a consistent number of people who will choose private practice. It’s true we need more primary care doctors overall, but of those people going into primary care a lot are still going into private practices. Along my interview trail, the number of residency graduates entering into private practice was 50-60% (of course this varies some depending on the program). Many of those people were also staying in the area where they trained. The remainder of people obviously went on to either fellowship or hospitalist jobs. My roommate said the same of her family medicine programs. She said it seemed much higher even at some places.
We will always need the community doc. They are the backbone of healthcare. There are just more options available now, so that people can truly find and focus on what they like most.
Another big difference in private practice is the size of the practices themselves. People are still pursuing private practice, but most graduates are joining larger practices.
It is almost unheard of now, a new graduate starting their own solo practice. I think the biggest driver of this is money. We are graduating with ever increasing education debt and malpractice insurance is steep. Combine that with the cost of starting a new business and it’s virtually impossible to start a new practice.
It makes sense to join an established practice, to learn the ropes from our more senior partners and one day probably take over the practice. I also think that younger physicians are more used to working in group settings – discussing difficult cases as a team. There is a push in medical school to focus more on team based learning which harbors a friendlier, more supportive, less competitive environment. It also encourages better communication.
Larger practice groups also allow for better call schedules and a better balance between work and home. It may be that we are a new generation with a new idea of what makes life a success. It may be that there are more women in the field and we are bringing out a softer side of things as we tend to struggle more than men with the balance between kids and work.
Fergus: Would you like to describe how you will consider this question and whether you will seek hospital, as opposed to private practice, employment?
Christina: I am truly undecided which path I will choose. There are so many options available. A lot will have to do with where I’m at in my life at that time and what I feel most interested in during residency. I am almost positive that I will not enter into solo private practice for the reasons I mentioned above. Hospital versus private practice…Who knows? I’m keeping an open mind to see what kind of work I really enjoy more. The nice thing about medicine though is that you always have the option of changing things up.
Christina Piron is a native of New Orleans, Louisiana, and a senior medical student at Wright State University in Dayton, Ohio.