Physician Perspective

Changes demand hard decisions for physicians

By Jean Edwards Holt, MD, FACS
San Antonio

From personal experience and years of anecdotal conversations, I have observed that the decision to become a doctor and begin the journey toward medical school admission is a tough one. As overwhelming as this decision may seem, it rapidly becomes evident it is just the beginning.

Each subsequent decision in a physician’s career path looms much larger and more significant than the previous one. What area of medicine — primary care vs. specialty? What specialty — academic vs. research vs. private practice? What type of lifestyle or location? How do you find time for family and yourself? What about income potential? Do you join a group practice, set up a solo practice, or obtain a salaried position?

A general rule in making decisions is that it is often helpful to list "wants" and "don’t wants" concerning the choices. Many times, there will be overlaps in these columns, so absolutes or non-negotiables must be identified.

For many students in medical schools, most clinical rotations are enjoyable, and the choice of residency seems impossible. "Wants" may include a desire to be the patient’s "real doctor" (a primary care physician, in today’s jargon) and yet have a special fund of knowledge (a specialist).

The ideal of giving ourselves completely to the profession and the patient must be balanced with a desire of having a family and nonprofessional fulfillment. In these cases, "non-negotiable wants" must be decided. A helpful non-negotiable in this decision path is a desire to perform or not to perform surgery. If this is an absolute non-negotiable, then enjoyable areas such as primary care, anesthesiology, and pathology are eliminated. If not, then forget making a decision based on specialty. This is a clear line in the sand to delineate a proper path. Many of the "wants" will not be compatible with this and will have to be discarded.

Once a specialty is chosen and achieved, how to use the skills learned can vary widely. Tradi -tion ally, clinical practice, academic medicine, or military service have been the primary choices. At this decision stage, alternatives in location, life style, money, and autonomy usually determine our final path. Due to externalities affecting our noble profession, changes are present, and more are on the horizon, forcing us to another fork in the road.

Simply put, it just isn’t as much fun as it used to be. Although there still is tremendous satisfaction in restoring vision to an elderly patient with cataracts or even providing a first pair of glasses to a young myope, there also are stresses of a demanding and litigious society, external demands of enforced rules (the hassle factor), marked decrease in reimbursement, and loss of autonomy. For many of us in the great healing profession, we sense frustration with our present situation and are asking, "What’s next?"

The nonmedical factor

In the past, the full-time practice of clinical medicine has involved "running a business" in only a modest sense. Receptionists, billing clerks, and technical or nursing personnel were in place primarily to assist the physician and move patients through the continuum of care.

With the introduction of "managed care," the nonmedical aspects of running a medical office now consume more than 50% working hours. Those tasks include obtaining referrals, checking on precertification, verification of benefits, contract negotiation, and resubmitting denied claims. (My office has dealings with more than 996 separate third-party payers, each with varying co-pays, deductibles, rules, regulations, and sub - mission criteria.)

Medicine has shifted from its role as solely a clinical science to that of a business. Instead of serving as the "captain of the ship," the physician is considered a "worker bee" and often as a "cost center." To be successful in this new environment, a physician must possess not only expert clinical skills, professionalism, and compassionate patient relations, but also business acumen. Unfortunately, business is an area for which we were not trained, and many of us may not desire to start that training now. Ignoring the transition, however, will lead to complete loss of autonomy, decrease in patient base, and less-than-acceptable satisfaction with the profession we have chosen.

Large single-specialty or multispecialty groups are joining to look more like businesses, hiring administrators, and allowing physicians to go about the business of practicing medicine. However, bringing groups of physicians together oftentimes creates the "tragedy of the commons" unless strong leadership can be supplied from the ranks and not just from the administrators.

This concept of "just doing what I do best" and leaving the management to others has been attractive to "true clinicians" and opened the door to the concept of physician practice management companies (PPMCs). The premise of the PPMC is to acquire medical practices, manage them on a day-to-day basis, (hiring, firing, billing, etc.), plus do the contracting, marketing, and strategic planning. Physicians are left to "see the patients." I’ll talk more about PPMCs in a future column, but for now, let me just state my prejudice that they represent the ultimate loss of autonomy we have been fighting.

An alternative to succeeding in this new business of medicine is not to relinquish control to others but to take control ourselves. True, we may not have the training, and we didn’t go to medical school to run a business. However, without our permission (managed care is a social experiment without the consent of the participants), the rules have changed, and our profession is no longer purely a clinical one.

It is no longer enough to be a professional scientific community. Increasingly, medical success depends on financial skills and business sense. These management skills may not be inherent to the physician, but with the level of intelligence required to be successful clinicians, they can be learned. Acquiring these new skills can place the physician in a leadership role to manage the new health care delivery continuum, just as the acquisition of clinical skills allowed successful management of the patient.

Most present-day physicians will need to seek out this business and management training in a similar manner to clinical training as a part of medical school. A few progressive medical school curricula are offering a new dual-degree program (remember the traditional MD-PhD combination?): the MD-MBA. The University of California at Davis and the University of Pennsylvania in combination with the Wharton School of Business, for example, offer combined six-year clinical and business programs.

Basic medical school curricula eventually may evolve in this direction (an absolute necessity!), but at the present time, supplemental instruction must be considered. Intelligent physicians can learn the needed business, marketing, negotiation, financial, economic, and legal skills.