Many doctors are leaving private practice and becoming employees of giant hospital systems. This is not because they want to but because of financial hardship – the cost of private practice is rising while payments and revenue are shrinking. According to the New York Times in 2002 70% of medical practices were physician owned and this dropped to below 50% in 2008.

I know a surgeon employed by a hospital on the East Coast. He finds that working for “the man” is not all that rewarding. He likes the certainty of income, avoiding the issues of hiring/firing and he no longer has to worry about billing and collections. This hospital like many around the country has emblazoned everywhere slogans about quality, “patient first”, and excellence. This surgeon feels these are false messages, more a form of advertising or proclamations.

The reality is that the hospital wants increasing efficiency and higher patient volumes. Like all his ‘partners’ he has a target he has to meet yearly so that his employer (the hospital) will pay him his full salary. Every time he sees a patient in consultation or operates, he generates a certain number of RVUs (Relative Value Units). A more complex consultation or more difficult operation is rewarded with more RVUs.

In private practice he ran 2-3 clinics a week where he could spend an hour or more with new patients. As an employee he can’t run more one clinic a week, as the department of surgery has a limited budget. It can only hire a small number of nurses and physician assistants all of whom are busy helping the other surgeons. In his one clinic he is given ½ hour for new patients and less time for follow-up visits. The financial targets are increased every year so all the surgeons have to generate ever more RVUs. In order to increase efficiency, my colleague was encouraged to see more patients in his clinic and cut new patient encounters down to 15 minutes. On most clinic days, he has no time for lunch. He was instructed find other ways to generate more RVUs, but his department would not be hiring any more staff to support this goal because of budget constraints. His busy schedule and lack of support also limits his availability to help colleagues when urgent consults arise.

He wonders if the same ‘higher-ups’ and administrators exhorting him to do more, could do their job with similar limitations in their support staff.

These factors are eroding his satisfaction at work and leading him to ponder leaving or retirement. When he told his supervisor, he was informed there would be no changes, the work volume and lack of support would persist and he like other doctors who have already left, could be replaced.

That is not the best method to make employees feel valued. The doctors and staff feel little respect from the ‘system’.

This constant push for more production really flies in the face of the proclamations posted everywhere about “patient first” and quality. There is a pathologic obsession with RVU production. Perhaps a move to a Value Based RVU system may help http://www.nejm.org/doi/full/10.1056/NEJMp1310583.

My overall sense is that those considering moving from private practice to becoming a hospital employee should carefully investigate the philosophy of the organization first.