How many times have you heard this?
"Doctors, especially new ones, just want to practice medicine. They don't want to run a business."
Well, obviously, you think. They're not trained to run businesses. Why not have the government run the clinics and pay doctors a salary? Everyone wins, and it's more efficient. It makes sense. The doctors pushing back are dinosaurs who don't know any better and are afraid of change.
Working as an employee suits some doctors. But there are tradeoffs; one way is not better than the other. It's easy for most people to see the downsides of doctors working as independent businesses, but perhaps less obvious what the downsides of working on salary are. Perhaps you can't understand why it's so hard to attract doctors to government-run clinics like UPCCs, when they pay reasonably well and appear to provide a better work-life balance.
But there are downsides, both for doctors and our healthcare system. Most of them involve various sorts of risks. And there broader consequences to consider? Who should control the healthcare you receive? Who is accountable? Do doctors provide unique value, or are they commodities?
NOTE: Physicians "on salary" are generally not hired as employees, with benefits, paid holidays, etc. Instead, they're independent contractors who agree to provide a fixed number of hours work for a fixed amount of money. The contracts spell out the obligations the physicians have around performance, paying for overhead, etc. So even though I use the word "salary" it's not meant to represent a traditional employer-employee relationship.
The "doctors just want to be doctors" trope is widespread. It's the government's argument for taking over (or driving out of business) independent clinics and replacing them with shiny new clinics run by professional managers. "We can do it better," they say. Obviously. But is it? Cui bono? Who benefits?
You hear all the time that new doctors just want to practice medicine, not run a business. If you ask them, it's largely true. Some of it has to do with hearing about how independent clinics are being devastated and not wanting to follow in their footsteps. For family docs especially, it's not a great environment to run a business. But that's not because of the running a business part.
Some doctors have a lot of experience in the real world before going into medicine, often having entirely different careers. Others go straight from high school to undergrad to med school to residency. They may have never held a "real" job, and spent much of the last 10+ years of their life working their asses off with their head buried in a book (or bowel, bladder, brain...).
They've spent their entire med school and residency working in hospitals, and were barely exposed to the practical side of things (ask any of the nurses who were stuck working with them). They're just finishing residency, overwhelmed with proficiency exams, on the verge of making big life decisions, and $100k+ in debt. They know that working independently involves learning some entirely new skills of which they're only vaguely aware. That leaves them nervous and uncertain. Now ask them if they want to start a practice for themselves or work in an environment they're already familiar with, taking a salary-based position in a hospital or other clinic where everything is taken care of.
No shit they'll take the salaried position.
But you know what? Many of them also haven't been homeowners, spouses, parents, investors, and all those other grown-up things that they'll eventually figure out how to do, asking for help when they need it.
As small service businesses go, medical practices are pretty straightforward. Sure, there's headaches around staffing and logistics, but no worries about marketing to attract customers, and the government (generally) pays your bills on time. And if they can't (or don't want to) do some of the jobs that come with running a business, they do what everyone does and pay someone else to do them.
This topic is very personal to me, so let me back up and tell you our story. For decades, I've owned, worked in, and worked with a variety of small businesses. At this point, I'd consider myself conventionally unemployable. At present, alongside a random collection of projects, I help my wife out with the business side of her practice. I've been doing this since well before she started practicing 18 years ago. She's worked in various settings, in large and small public hospitals and cancer centres, various health authorities, on salary at a private hospital, in primary care networks, and in independent private practice. Pauline is a fantastic psychiatrist. But she's the first to admit that she's lacking in certain practical skills. I've helped her with many of the practical aspects of her work and helped her navigate (or avoid) various tricky situations involving skills that were completely outside anything she learned in school. I like to think I bring something to our marriage other than being a great cook.
When you have no decision-making authority but are held responsible for the consequences, it can end very badly.
Most doctors find this out the hard way, and it usually happens pretty early in their careers. Doctors have a lot of responsibility. Ultimately, if something goes wrong and the shit hits the fan, the doctors are the ones held accountable for it.
Even if they're not at all responsible, some situations, especially when they evolve into medicolegal disputes, can be a huge pain in the ass for doctors. Here's an example. In one of her very last clinical shifts as a medical student, Pauline was involved in a case that had a very bad outcome. Significant mistakes were made (by others; she was actually the one who caught them). The patient's family sued, as they rightly should have. She was included in the suit, along with a pile of other doctors, medical staff, the hospital, etc. Medical students have zero ability to act independently are generally not held responsible for anything in situations like this, but someone had mistakenly referred to her as a resident (i.e., with an MD) in one of the chart notes. Once that error was pointed out, she should have been dropped from the lawsuit immediately. But, despite pleading, there was no advantage to the plaintiff's lawyer to do so. They kept her in to use as a bargaining chip down the road. She was eventually dropped before the case finally settled. But that followed her around for six years and came up every time she had to deal with licensing, hospital privileges, etc.
Ask anyone in any large organization about inane decisions and dysfunctional management and they'll have stories. Healthcare is definitely no exception. Most doctors could write a book about the idiocy they've personally experienced. I'll spare you any specific examples.
When doctors work as employees in organizations, the resources they have available, and often how they practice, are frequently outside of their control. Given the choice, it's not how they would choose to practice. It's not uncommon for doctors to be put in situations that, on reflection, did not allow them to practice medicine in a manner that was safe, acceptable, and professional. Not because of their decisions but those of others.
But if something goes wrong, who is ultimately responsible? Doctors. If there's a screw-up, it's on them, not whoever made the decisions.
As we all know, "I was just following orders" isn't a valid defence.
Now put yourself in a situation where the people making decisions have very little clue about the work you do, are trained in entirely different disciplines, and have very different priorities. They also aren't held professionally accountable if things go wrong. Most of them are not trained as managers, and many do a terrible job as managers. But because there is so little accountability within large bureaucracies like health authorities, they often think they're doing a fantastic job, even when (depending on your perspective) they're running the place into the ground. Frequently, nobody tells them otherwise or even notices. And this includes many doctors in managerial and administrative positions. If you're smart enough to practice medicine, managing people and budgets is a cakewalk, right? (No)
So what's the potential downside for a physician of working as a salaried employee in an organization? They may be paid well and sometimes have better work-life balance. But working in an organization where you're responsible for the consequences but have no say in decisions can bite you hard. And even if it doesn't, for people who feel their workplaces are completely dysfunctional, it's often hugely frustrating and can feel like it's sucking the life out of them. Early career doctors haven't necessarily lived that, at least at first.
I'll wait here for a minute while you ponder why the UPCCs have had such difficulty attracting and retaining doctors.
In this whole discussion of primary care and how doctors are compensated, I've talked a lot about the value of incentives. Money is only one of them, but it's an important one.For doctors working independently on FFS, they only get paid if they see patients. That motivates them to work hard. Running your own practice also motivates them to manage their practices wisely. Every dollar that they spend is a dollar that's not going into their pocket. They very clearly see the consequences if they're spending money on things that don't improve their practice. If they're smart, they'll either figure it out themselves or pay someone to figure it out for them.
Contrast that with government-run clinics. There's intrinsic motivation to work hard and do a good job, but beyond that? And if an extra $1 million gets spent here or there, who's going to notice? There are few consequences, little accountability. Other things being equal, that's going to be less efficient.
And why wouldn't the government want to offload the financial risks onto doctors, rather than assuming themselves? If they screw up, it's out of their pocket, not yours. Really, why wouldn't they?
A big part of it comes down to control. And that comes down to power.
Government has long tried to recast doctors as commodities, interchangeable cogs that can be replaced at will. One doctor is as good as another. And in fact, maybe a nurse practitioner, nurse, health care aide, or even someone with no training might be better doing certain things.
They've tried to reduce their decision-making authority, agency, and independence.
They've mandated NDA's and gag orders so that doctors cannot speak up about failures in the healthcare system. They are no longer able to advocate effectively for their patients. And frequently, they're scared to even advocate for themselves.
Government wants doctors and other health care practitioners to work on their behalf, not yours.
Don't let them.
If looking around here isn't enough for you, look down south for how badly things can go. In the USA, there's been a massive shift to mega-corporations (hospital networks and HMO's) buying up smaller hospitals and clinics. The formerly independent physicians are tightly controlled and told what they can and cannot do. They aren't making the decisions on patient care. Spend a few hours reading a physician forum like KevinMD. Doctors are stressed, hopeless, and defeated. Job satisfaction is nil. Burnout and suicide are on the rise. Many are not only quitting jobs but quitting medicine altogether because there aren't any independent opportunities left. Everyone has a side gig and is working on their exit plan. We're going down that road too, but have time to turn back.
I've talked a lot about the downsides of doctors taking a salaried position, but there are also obvious upsides.
There's no one-size-fits-all solution that works best for everyone.
The best option is to offer physicians a choice as to how they want to practice and how they want to be compensated. Ultimately, it's not about how they're paid but whether or not they're paid fairly.
I'll leave you with one other thing to consider. Pauline has what could be considered a "boutique" private psychiatry practice. She follows people and provides excellent care. And because I've picked up a few things over the years, I can take care of a lot of things that leave her free to focus on what she's good at. Between the two of us, we provide what I think most people would agree is an exceedingly high level of service and responsiveness to patients and the doctors who refer to her. It far exceeds what she'd be able to provide working at a health authority with limited access to admin staff, etc. And what does all this extra service cost the government? Absolutely nothing. Actually, they save money compared with if she was working for a health authority. It's a choice that she (we) made about how she wants to practice medicine.
Don't take that choice away.