Even though financial and legislative challenges are making it harder to be a physician, docs tell us they haven't given up.
Many physicians would probably tell you overall they are happy, love their job, and if they had the choice, would do it all over again. While that doesn't mean running a medical practice has become easier, it does mean that physicians are finding plenty of avenues for job satisfaction. And there is still room to carve out a practice style or model that works for each individual.
Alan Menkes, an internal medicine physician who works for a telemedicine company, is "seeing" his patients virtually through video chats and telephone calls. It was a conscious choice for him to slow down and choose family time over a greater salary. He has had a long career working in diverse practice settings, but in anticipation of the birth his daughter, he decided to slow the pace.
"My military contract was up in October, I had a baby on the way, and I made a life changing decision. Let me work from home on telemedicine. I don't want my tombstone to read, 'I wish I had made more rounds at the ICU,'" Menkes says.
Even though he's made the choice to slow down, Menkes says he loves being a physician and has never regretted his career decision. His outlook mirrors that of the physicians we surveyed in our 2015 Great American Physician Survey, Sponsored by Kareo. Physicians tell us while they are frustrated with factors such as increasing third-party interference, they overwhelmingly like being a physician. And they seem to be doing a better job of balancing personal and professional obligations. Here's how they are doing it.
*If you'd like to see how you measure up compared to your peers, visit the full results of our Great American Physician survey.
DOING IT MY WAY
Despite recent bellwether changes taking place in government programs like the elimination of the Medicare Sustainable Growth Rate formula and possible softening of requirements for meeting meaningful use, the physicians who responded to our survey indicated that "too much third-party influence" is still a major irritant to practicing medicine. Forty percent of respondents claim that is their biggest frustration with being physician. Contrast that with 13.8 percent (the second highest-scoring answer) who said their declining ability to practice independently caused the most angst.
Likely that frustration is aggravated by feeling impotent when it comes to influencing government programs and mandates, like meaningful use of an EHR or adopting ICD-10. In fact, many physicians that we spoke to say they have little to no influence over how they will implement government mandates in their practices, nor do they have the time to become involved with local politics or lobbying groups like state medical societies to try and change that. But they are dealing with that frustration in a variety of ways, and by no means are they throwing in the towel.
Nick Hernandez, CEO of ABISA, a consulting firm specializing in small-group practice management, agrees that physicians can feel powerless, and says often times they seek out employed positions so that their employer can deal with government demands. "Most of the docs I talk to feel like they have absolutely no power whatsoever when it comes to government influence. … And so the docs are going toward the employment model. … One of the reasons is because they don't have to worry about having to fight with government [mandates] and regulatory issues breathing down their neck," says Hernandez.
Thirty-nine percent of the physicians who responded to our survey say they were employed by a hospital or other institution, 30 percent said they were a partner or co-owner of a private practice, and 12 percent said they were employed in a private practice. Those numbers are essentially unchanged from last year's survey, suggesting that the push to become employed has stabilized. Menkes thinks that choosing employment has a lot to do with tenuous financial stability, especially for younger physicians just starting out in their careers, who often carry significant debt from medical school.
Vikki Stefans, an associate professor of pediatrics and physical medicine and rehabilitation at Arkansas Children's Hospital in Little Rock, experiences her own frustrations working for a large academic institution, but she is not without avenues of release. Most physicians are too busy to be politically active, she says, but "there are a lot of physicians who have time to let off a little steam on SERMO [a physician social networking site], or something like that, but wouldn't have the time to learn all the issues from all the points of view, and spend time with politicians."
Stefans believes that physicians are becoming more active online, through social media platforms like SERMO and Doximity, and says that because her busy days don't allow for "chit-chat time" with fellow physicians, she enjoys the opportunity to learn differing points of view online. She points out that technology is a way for her to connect with other physicians, rather than being an obstruction to her work.
A CHANGE OF SCENERY
Working in a solo or small-group practice is often touted as the best path to physician satisfaction. That is not always the case. Mark Birmingham, a podiatric surgeon who started his medical career working in a private, single-specialty practice near Chicago, admits the pay was good, yet in terms of professional satisfaction and work-life balance, there was something lacking. "I was well-compensated, but I did not have the professional accomplishment that I was looking for," he says.
Birmingham moved his family to Boulder, Colo. and joined the orthopedic department of Boulder Medical Center, a multi-specialty group practice. He says the move reaped both professional and personal gains. "I feel much more accomplished professionally here than I did at [my old] practice. My family is doing a lot better. … We live in a big neighborhood with a bunch of young families, my kids walk to school, [and] my wife is around other like-minded mothers."
Physician compensation has remained flat over the last several years according to the latest Physicians Practice Physician Compensation Survey (bit.ly/revenue-streams), but that doesn't mean that physicians aren't finding ways to combat that trend. For instance, employed physicians are beginning to rejoin the ranks of physicians in independent practice; new practice models are opening up avenues for increased revenue opportunities for mid-career physicians; and physicians are finding ways to supplement their practice income, such as operating an ambulatory surgery center.
Thirty-three percent of the respondents to our 2014 Physician Compensation survey said they had increased the number of patients seen per day to bring in more income; 29 percent said they had taken on work outside their practice; and 23 percent had added ancillary services.
Birmingham acknowledges that he'd like to earn more income. He says he would need to see two patients in Colorado to bring in the same reimbursement as one patient would in Chicagoland, but concedes that the reduction in income was worth it.
"I knew that moving out here would be different. But at the same time, I wanted to be in a different practice and this is a great set up," he says, "… But now, [for physicians in general] our compensation is getting so low that we actually have to like our job. Truly, you really have to have a love for the patient. You have to have their best interests at heart."
Roughly one-third of the physicians we surveyed said they were either working in a concierge practice or considering changing to that practice model. Those numbers are essentially unchanged from last year. While 10 percent of docs said they thought concierge practice was bad for the healthcare system, that number is slightly less than last year's survey.
There are several variants of concierge medicine like hybrid-concierge practice or direct-pay practice that may have something to do with better acceptance by physicians, as they allow traditional patients to remain in the practice without paying a substantial yearly retainer. Proponents say the greatest benefit to physicians, aside from more time to spend with patients, is the ability to contract directly with patients and eliminate the third-party payers.
However, not every physician is in a position to radically change her practice model in that manner. Menkes points out that in order to successfully make that change, physicians must be well-established in practice and have at least 300 patients to 500 patients who are willing to pay the $1,500 annual fee, for example. He says it is economically impossible for young doctors who are new to practice.
Other physicians like specialists are much more reliant on referrals from primary-care physicians to keep their practice running and may be less inclined to open a concierge practice. Although even that is beginning to change.
(If you are interested in learning about a cardiology concierge practice visit bit.ly/heart-concierge.)
The Affordable Care Act still remains a lightning rod for dissention, but physician support seems to be growing slowly. Fifteen percent of physicians in our survey said, "I think the reform law has been great for Americans," 47 percent said, "I think the law is mostly good, but not all good," and 38 percent said, "I think the law has done a disservice to Americans." Forty percent of physicians said they saw no discernible change in their practices due to the reform, 31.6 percent said collecting patient deductibles has become more challenging, and 21 percent said they see more chronic-needs patients. Surprisingly, 70 percent of survey respondents said they've treated few patients with new exchange plans.
Stefans thinks the reform law has brought much-needed services to her patients' family members. "It's not perfect … but the idea that working age Americans age 18 through 65 have some kind of coverage is ultimately important. I was very much for it. … The moms of my myotonic dystrophy patients who need care for themselves, a lot of them were not getting it, now at least there is the option and the opportunity for them to have some healthcare," she says.
BALANCING WORK AND HOME
Millennials, young adults who were born between 1980 and the mid-2000s, value community, family, and creativity in their work, according to a 2014 report by The Council of Economic Advisers. This trend is also reflected in young physicians. More physicians starting out in their career are choosing employment by large health systems or group practices, rather than starting an independent practice. They are often unwilling to put in long hours at their practice and the hospital, shrinking available time for family and children.
Hernandez concurs. "Ten years ago [young physicians] were coming out [of school] and still wanted to start their own practice … with the hopes of being a partner some day. Now more often than not, they … just want to roll into some employment where they don't have to worry about it," he says.
Whether you are an employed physician or work independently, there are some universal truths. According to our survey, over half of responding physicians said they wish they could spend less time at the office. Twenty-eight percent said they work 41 to 50 hours a week; 25 percent said they work 51 to 60 hours a week; and 25.5 percent said they work up to 40 hours a week. Yet, unlike Menkes and Birmingham, 54 percent said they would not be willing to give up salary or other benefits to work less.
Of the 39 percent of physicians who said they wished they could change workplaces, 26 percent said their reason was to get more time for their personal life; 36 percent said to get away from an unhealthy workplace culture; and 13 percent said to make more money.
TECHNOLOGY TO THE RESCUE
Stefans says she has not found an ideal work-life balance yet. In fact when asked if she has a good work-life balance, she says, "There's any number of things you have to give up because you are on call or you are trying to catch up on paperwork." She admits that she could do better with time management and says, "I take a little bit of time for myself to exercise, but not much else. I have too much sitting time." She explains that "paperwork is the bane of my existence," and says there is simply too much of it.
Stefans says she prefers her EHR to paper charts, and feels that technology has made her life much easier. She thinks patient information is easier to find and access in the EHR, and even better, Stefans doesn't physically need to be at the hospital to review charts or imaging studies on the weekends or evenings.
She says her institution's EHR is "not a great system. That said, I'd rather have that than wade through a paper chart any day. A bad day on the electronic system still beats a good day on the paper system."
TECHNOLOGY AS A STUMBLING BLOCK
Not all physicians enjoy their EHR like Stefans. In fact, many older physicians feel that it contributes to their career dissatisfaction. Meryl Luallin, a San-Diego-based consultant/partner with SullivanLuallin, says, "There's still a lot of complaints, particularly from the older doctors, that EHR has come in between them and their patients. … I don't hear that from younger doctors - younger patients are busy texting while the doctor is inputting the data."
Experts say complaints include difficult-to-use EHR systems, too much time inputting patient data, too little time spent connecting with patients, and less daily productivity. When Menkes was still working in a medical practice, he made a point to give his full attention to his patients, who were incredulous but appreciative, stating, "Doctor, it is amazing you are actually looking at me and talking to me, and not the computer."
*If you'd like to see how you measure up compared to your peers, visit the full results of our Great American Physician survey.
Physicians tell us they continue to enjoy their professions, patients, and home life. But it’s not all rosy. As healthcare reform continues to evolve, docs will need to be creative about the ways they alter their practices. Areas of change include:
• Working with government mandates and new programs
• Choosing the right mix of independence vs. employment
• Maximizing compensation while preserving work-life balance
• Learning to work with technology, while continuing to connect with patients
Erica Spreyis associate editor for Physicians Practice. She can be reached at firstname.lastname@example.org.
This article originally appeared in the September 2015 issue of Physicians Practice.