Stephen J. Rockower, MD

 unveils its list of "Best States to Practice" for 2014, I thought I'd weigh in on where I practice: Maryland. There are many challenges here. Maryland is among the highest ranked states in costs of living and the lowest in payments from insurance companies. Our state's new waiver (the only one in the country) obligates physicians to partner with hospitals for payments. That certainly is not going to go well. The waiver has provided over the years for a stable hospital system, but the physicians are often left out of the equation. It took many years of work to get compensation to trauma docs when the hospitals were already being paid. As an orthopaedic surgeon, I am prevented from providing ancillary services such as an MRI by legislative direction. There is increasing penetration of hospital systems employing physicians, especially the younger ones just out of training. Will these docs be able to make a career of it? Will they become embittered by labor relations?

We live in an oligopoly of insurance. There are a few major players with a number of smaller companies. Every other year, one company or another sends my practice a letter citing "marketplace pressures" in announcing their new pricing structure. Some private practices have been able to negotiate, but most don't have the clout. There have been some recent consolidations to create larger private practices of gastroenterologists, OB/GYNs, orthopaedists, anesthesiologists, and urologists, but time will tell to see if they have the wherewithal to negotiate effectively.

All of our hospital systems are upgrading to computerized physician order entry (CPOE). This wonderful "upgrade" transforms physicians into non-paid clerks for the hospital. One system even told us in their training that one of the purposes of CPOE is to generate extra cash for them. No two systems are alike, and the order entry system differs widely. I managed to somehow order 430 mg of Coumadin for a patient my first day (with three trainers standing around me). Luckily, a smart nurse picked that up and saved me and my patient. I suppose this is happening everywhere in the country, as data becomes king, and efficiency is measured in keystrokes.

Physicians try to make things better, but it sure seems like a 

 uphill battle. As a member of the organized medical community (local and state medical societies) of our state, I work with others to influence the decision makers to bend the curve in our direction. We are able to advocate for patient care, tort reform, Medicaid reform, workers' comp reform, and new health IT solutions. Living close to Washington, D.C., we are able to easily talk to legislators on Capitol Hill. Many physicians think their specialty societies are their only voice in the legislature, but the state medical society (MedChi in Maryland) speaks for and advocates for all of us. In my dealings with legislators, they are often greatly influenced by, "What does MedChi think?"

I continue to live here because I like the cultural activities the Washington metropolitan area has to offer. The museums, theater, music, restaurants, and cultural attractions rival any major metropolitan area in the world; without the bustle and dirty air of, say, New York or Los Angeles. Our beaches are only a few hours' drive and the mountains a few hours in the other direction. Yes, the traffic sucks, but driving past the White House, the Lincoln Memorial, the Washington Monument, and the U.S. Capitol still sends a wonderful shiver up my spine, even after living here for 38 years. If I really wanted to make lots of money, I could certainly go elsewhere. I choose to stay here and make a difference.

is an orthopaedic surgeon, practicing in Rockville, Md., and a member of the 

 Physician Advisory Board. What keeps you practicing medicine in your state? Tell us at editor@physicianspractice.com. Unless you say otherwise, we'll assume that we're free to publish your comments in print and online.

This article originally appeared in the October 2014 issue of 

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If I really wanted to make lots of money, I could certainly go elsewhere. I choose to stay here and make a difference. 

Author | Stephen J. Rockower, MD

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