Changes in Medicine: the Decline of Physician Autonomy

Reference as: Robbins RA. Changes in medicine: the decline of physician autonomy. Southwest J Pulm Crit Care 2011;3:49-51. (Click here for a PDF version)

Thirty years ago when I left fellowship, there were predominantly two career paths, private practice or academics. I had chosen academics by virtue of doing a fellowship at a heavily research-based program, the National Institutes of Health (NIH). However, even at the NIH many of my colleagues eventually ended up in private practice, which was more lucrative and much more common than the academic practice I chose. Now a third path has become more common, practice as a hospital employee. I became a hospital employee over 30 years ago when I became a part-time, and later, full-time physician at a Department of Veterans Affairs (VA) medical center affiliated with a university. Apparently I was ahead of my time. In an article entitled “Majority of New Physician Jobs Feature Hospital Employment” 56% of physician search assignments by the national physician search firm Merritt Hawkins in 2011 were for hospitals (1). This had increased from 51% in 2010 and 23% in 2006. In contrast, only 2% of the firm's 2011 search assignments featured openings for independent, solo practitioners, down from 17% in 2006. "The era of the independent physician who owns and runs his or her practice is fading," according to Travis Singleton, a senior vice-president at Merritt Hawkins.

The reason that hospitals want to employee physicians is obvious-money. By increasing market share and collecting professional fees, hospitals profit from physician employment. Physicians may be fearful of the cost of setting up a private practice with the increasing uncertainties of reimbursement, making a salaried hospital position attractive. This is especially true for a new physician not wishing to add to the debt incurred during training or seeking less than full-time employment for family or personal reasons (2).

Although quality or efficiency is often touted as a major reason for hospitals to employee physicians, recent research suggests that neither result. Kuo and Goodwin (3) reviewed over 50,000 Medicare admissions and found that hospital length of stay was 0.64 day less and costs $282 lower among patients receiving hospitalist care compared to primary care physician care. However, this reduction in inpatient costs under the care of hospitalists was more than offset by a $332 increase in charges after discharge.  Furthermore, patients cared for by hospitalists were less likely to be discharged to home; more likely to have emergency department visits; more likely to be readmitted to the hospital; less likely to have a follow up visit with their primary care physician; and more likely to be admitted to a nursing facility. As the authors point out this is nothing more than cost shifting, and hospitalists, who are typically hospital employees, may be more susceptible to behaviors that promote cost shifting. Consistent with this concept, O’Malley et al. (4) state that hospital employed physicians increase costs by higher hospital and physician commercial insurance payment rates and hospital pressure on employed physicians to order more expensive care.

Although the disadvantages of hospital employment are several, “Ultimately, the loss of control over their own professional lives is what irks employed doctors the most…” (5). As someone who worked as a hospital employee for the VA for over 30 years, I found an increasing “master-servant relationship” particularly annoying. Decisions were often based on financial or political considerations by nonphysicians or under-qualified clinicians. For example, some have recommended propofol as a standard in conscious sedation (6). It offers a number of advantages including ease of titration and short duration of action. Propofol has been used by our group for years in the ICU. Our group applied for “privileges” to use propofol for bronchoscopy which was endorsed by the pharmacy and therapeutics committee. Yet, the clinical executive board denied the application which our group found puzzling.  I was later told by a quality assurance nurse that the basis of this decision was that propofol is what killed Michael Jackson.  Hopefully medical decision making meets a higher standard than the singular example of what may have happened to a pop star.

Another example is the guidelines from groups like the Institute for Healthcare Improvement (IHI) that quickly becomes hospital mandates. Many of these guidelines are, at best, weakly evidence based (7). Furthermore, the guidelines are bundled, i.e., several guidelines are grouped together. Bundling makes it difficult, if not impossible, to determine which guidelines are effective. Most have probably had little impact on patient outcomes, but at least one proved to be catastrophic. Tight control of blood sugar in the intensive care unit was mandated and monitored by the VA based on IHI recommendations. However, as demonstrated in the NICE-SUGAR study, tight control actually resulted in a 14% increase in patient mortality (8). This increase in mortality would translate to 9503 excess deaths at all VA hospitals between 2002 and 2009 or about 1 death for every 84 patients treated with tight control of glucose. After publication of the NICE-SUGAR study the IHI dropped the issue from its web site and the VA switched to also monitoring hypoglycemia. One might think that a guideline which resulted in a 14% increase in ICU mortality would cause an outcry to punish those responsible, but instead resulted only in a deafening silence.

I am hopeful that we have trained our young physicians to practice for their patients’ benefit, rather than the financial or political well-being of the hospital. Yet, I fear that the financial pressures of beginning practice and protecting one’s reputation and livelihood may be too great a pressure to resist. Until physicians are not supervised by non- or under-trained administrators in a “master-servant” relationship, incidents such as the increase in ICU mortality secondary to tight control of glucose are bound to reoccur.

Richard A. Robbins MD

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Crane M. Majority of New Physician Jobs Feature Hospital Employment. Medscape 2011. http://www.medscape.com/viewarticle/744504?sssdmh=dm1.695421&src=nldne (accessed 8-22-11).
2. Robbins RA. Changes in medicine: medical school. Southwest J Pulm Crit Care 2011:3:5-7.
3. Kuo Y-F, Goodwin JS. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med 2011;155:152-9
4. O'Malley AS, Bond AM, Berenson RA. Rising hospital employment of physicians: better quality, higher costs? Center for Studying Health System Change (HSC) 2011. http://www.hschange.com/CONTENT/1230/#ib5 (accessed 8-23-11).
5. Terry KJ. Six biggest gripes of employed doctors. Medscape Business of Medicine 2011. http://www.medscape.com/viewarticle/737543 (accessed 8-22-11).
6. Eichhorn V, Henzler D, Murphy MF. Standardizing care and monitoring for anesthesia or procedural sedation delivered outside the operating room. Curr Opin Anaesthesiol 2010;23:494-9.
7. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
8. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.