Adapted from comments given at the University of Alabama-Birmingham, February 28, 2015.

Here’s a conversation that isn’t getting much air in polite conversation. The profession you’re aspiring to join has changed. There are some things that you should know about being a physician that you probably aren’t being taught.
If you stay involved in clinical practice, you’re likely going to be an employee.
Once upon a time, physicians owned and managed healthcare in the U.S. In an amazing and largely untold story, physicians ceded control of healthcare to corporate interests back in the 1970s (it was at this time that HMOs gained prominence). Why did this happen, you may ask? This was no occurrence of grand design. After long, hard days caring for patients, doctors mainly just wanted to spend more time with their families. The opportunity to turn over the administration of healthcare to outside interests didn’t seem like such a bad idea as long as physicians still had freedom to care for there patients as they saw fit, and they continued to make a relatively handsome living.

That’s right, physicians just handed over what is now a $2 trillion business in the U.S., representing approximately 17% of the gross national product.

However that was just the beginning of the story. These corporate interests and new ones have very successfully played the “long game,” incrementally eroding physician’s autonomy to practice the art of medicine. A majority of physicians now work for hospital systems, contract management groups or other corporate entities and are subject to the typical controls an employer exerts over an employee, particularly those without union protections. Entire medical specialties practice without basic employee protections, such as due process in the face of disputes. In all probability, your doctor’s office no longer belongs to your doctor.
It’s sad to say, but this results in your healthcare providers no longer just having your wellbeing as their sole and primary concern. The incredibly large and profitable corporations for which they work have expectations for financial success, and that success is being delivered by the actions and inactions of your physicians. (Don’t think for a second that many of the largest buildings in this country are owned by insurance companies by accident. Think about how much additional cost is introduced into the system by the existence of these third parties and their massive infrastructures.)
Such is the case now that more than one thing can be true. Your healthcare provider has options in terms of how you are treated, and there are incentives beyond your clinical care that determine which option is chosen. The unfortunate reality of medicine is exercising these options doesn’t have to reach the level of fraud to be effective in producing optimal financial results while providing adequate clinical care. However, even without fraud, the existence of these consideration means your care isn’t what it could otherwise be.
The ultimate irony is the system continues to present physicians as the face of healthcare, as if the goodwill you have with your individual primary care physician is a result of factors under her or his control. Of course after all that is said, your physicians are still the ones who can be sued for outcomes produced by corporate decisions. For example in hospitals, physicians don’t even control the medications and equipment that are kept in stock for use in their practice and are often made to use medication and equipment that would not be the best choice in their judgement. The committees that make these decisions include individuals whose salaries actually include considerations of minimizing (which is different than “controlling”) costs. The unfortunately reality of today’s medicine is enough plausible deniability exists to claim that such cost-control measures are good medicine, when in fact it’s good business. Check the data. Profits in healthcare continue to rise. Patient outcomes? Not nearly as much.

“Look, Doc! No one’s on their smartphones!”

What does this part of the conversation mean for you? You are still the final frontier of quality. Yes, you have a responsibility to work within the system to be both clinically and financially responsible, but your first calling is to “Do No Harm.” Your choosing to practice medicine means you accept the responsibility to simultaneously work within the system and fight the system when appropriate. After all, it will be your individual licenses on the line when you care for individual patients. Always do the right thing for your patient, and most everything else will take care of itself.
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