Healthcare Reform Influencing Physicians' Career Choices

Following a four-year overseas tour in the Army, family physician Beau Ellenbecker opened a two-physician practice in Roanoke, Texas, in August 2011. But Ellenbecker opened the practice not as an owner, but as an employee of a large healthcare system.

"I think doctors in past generations were a little bit more entrepreneurial," he says. "When they went into medical school their desire was to own their own practices, and nowadays that thought didn't occur to me." Instead of practice ownership, he says, he wants assurance "that my employees are going to get paid, that I don't have to bleed my knuckles to make sure that all my overhead is covered and whatnot, and then worry about where my paycheck is at the end of the day."

Ellenbecker's preference for employment is one of many major shifts in attitudes toward work and life underscored by the results of our latest Great American Physician Survey of U.S. physicians. More of you are pursuing less demanding work schedules and exploring new models of care while feeling less optimistic about the future of medicine in general.

From generational differences and uncertainty due to healthcare reform to skyrocketing stress and frustration with traditional fee-for-service reimbursement, here's a look at some of the key factors that are changing your attitudes and career preferences.

*To read the results of the 2012 Great American Physician Survey view our slideshow here.

Ease of employment

Twenty-nine years ago, family physician Robert Carter opened a solo practice in Savannah, Ga., and he's happily practiced there ever since. "It was just one of those things that when I finished school, it wasn't written in stone, but many people started their own practice or went into other small practices," Carter says.

Now, with his two children in medical school, the 60-year-old sees how much things have changed. Though neither of his children has decided whether they prefer employment to private practice, most of their peers have. "Both of them had opportunities to work in my office for many years as they were growing up so they know what it's like, but they hear everybody - all their classmates - talking about 'I wouldn't dare consider going into practice for myself,'" says Carter.

This sentiment among young physicians has skyrocketed over the past decade. In 2001, only 3 percent of final-year medical residents said they would prefer hospital employment over any other option; in 2011, 32 percent said they would, according to physician search firm Merritt Hawkins' annual surveys of final-year medical residents. "Residents told us we're ready for the practice of medicine, but we don't want anything to do with the business of medicine," says Kurt Mosley, vice president of strategic alliances for Merritt Hawkins.

Young doctors worry that practice ownership will mean too much time spent on administration, too many long hours at the office, too much stress and financial risk. Employment just seems safer and simpler. And while previous generations of physicians were more willing to accept those presumed drawbacks because it meant independence and potentially higher incomes, younger physicians have different priorities. "I definitely think that their preference is this lifestyle/work-balance area," says pediatrician Walker Ray, vice president of The Physicians Foundation. "I think they have looked at physicians' practices and the practice styles in the past and said, 'That's not what I want to do, I don't want to work a 60- or 70-hour week.'"

Indeed, only 4 percent of Great American Physician Survey respondents over age 65 said they would give up partnership in exchange for a reduced workload. Yet 21 percent of our respondents under age 35 said they would.

Solo family physician James Robusto, who has practiced in Urbanna, Va., for 26 years, worries that young physicians are missing out on the fulfillment gained from working in a private practice. "When I'm working for myself, I know for one thing that the patients come first, and that is simply the way it's going to be," he says. Still, he acknowledges that entering private practice today is more challenging than it was in the past. "…The government regulations are now a lot worse than when [older physicians] first came out," says Robusto.

Ray agrees: "Healthcare reform and the market forces are pushing physicians further in a direction that they are already heading, which is either out the door or away from the traditional independently owned practice model, which they see as being unsustainable," he says.

Seeking balance

In preferring employment over partnership, many physicians - especially younger doctors and women physicians - are placing a higher premium on flexible schedules than previous generations did.

This comes as no surprise to Ellenbecker, who says the demanding work hours are one of the biggest drawbacks of a career in medicine. "Any time somebody asks me, 'Should I go into medicine?' … I tell them, 'Well you know, you have a loss of personal time - that's the biggest thing.'"

Forty-eight percent of you say you wish you worked fewer hours per week, and 66 percent of you say you don't have as much time for your personal life as you think you should, according to our survey. But younger docs are more willing to make sacrifices for more personal time: Among physicians under 36 who said they're overworked, about four in 10 would be willing to earn less if it meant working fewer hours. In other age groups, pluralities or majorities of overworked physicians say they can't sacrifice anything in exchange for more personal time.

This demand for greater balance, says Ray, can be off-putting for older physicians who recall their own grueling schedules and wonder, "Why can't they work as hard as we [did]?" Yet older doctors are also beginning to understand where their younger colleagues are coming from. "Maybe we worked too hard, maybe we missed too many birthday parties, or too many graduations, or too many anniversaries," he says. "Our kids grew up and we were either too tired [to spend time with them] or away."

Indeed, the fastest-growing groups of part-time physicians are women aged 35 to 44, who want more family time while the kids are young, and men over 55, who "feel like they've put in their time, they've put in all those hours, and they deserve a little bit more free time to do the things that they enjoy," says Lori Schutte, president of physician recruiter Cejka Search.

Opening minds

Another trend is the growing acceptance among physicians of alternate models of care, such as concierge medicine, direct pay, and membership practices. In 2009, 17 percent of you said so-called "concierge practices," in which patients pay an annual fee to their physicians for access to care, are bad for the healthcare system or unethical. In 2012, that number dropped to 13 percent, according to our survey. Ellenbecker says he's seen this growing acceptance of such models firsthand. "I have friends that used to think it was a crazy idea," he says. Now they are asking "Have you thought about this?"

This growing acceptance is "a trend that has to do with the dysfunctional healthcare financing system," says American Academy of Family Physicians President and physician Glen Stream, a family physician. "It's a way for the practice to work around the insurance company and all the hassles that come with that, and it also helps the patients work around that - so for some folks, it's a good option."

As Stream notes, fee-for-service reimbursement is a huge source of frustration for physicians. Due to declining reimbursement, most of you are forced to squeeze more and more patients into your day to keep revenue stable, says Ray. "There is no breathing room now."

These alternate models of care, on the other hand, enable physicians to break away from fee-for-service. "It comes back to letting the doctors go back to their roots of practicing medicine in the best interest of the patient," says Mosley.

A small, but growing number of physicians are moving beyond accepting such models to adopting them. Nearly 10 percent of our survey respondents said they are considering or are already working in a concierge-type practice. One is family physician Jennifer Chilek. She transitioned her two-physician Montgomery, Texas-based practice into a membership practice in April. Her patients pay her a monthly or yearly fee for access, plus regular service fees. In return, she spends more time with them and provides them better access to care. "I looked to do this for several years and finally decided it was time," Chilek says. "I didn't see anything in the future that was truly going to help our situation, and I felt like my volume of care was going to need to increase, and I knew that that was going to go against the way I wanted to care for my patients."

Future fears

The final trend is the declining number of physicians who say they would recommend their children follow in their footsteps. This year, only 28 percent of our survey respondents said they would; that's a 10 percent drop since last year. Although most respondents say they prefer not to meddle in their kids' career decisions, one in five would now actively discourage a career as a physician. "I think any physician would be pleased if their child went into medicine, but I think any physician would say, 'Listen, it's going to be a hard time and you need to be aware of what you're getting into,'" says Ray. "The older generation is disaffected with medicine and does have concerns about the direction medicine is going, and they're not recommending wholeheartedly that their children become physicians."

It is true that the way medicine is practiced in the future will differ greatly from how it is practiced today, says Mosley. One of the biggest changes, of course, will be to the volume-based reimbursement system. "Fee-for-service is going by the wayside; it has to," he says. But it's not clear what will replace it. Such a major transition will also initiate more changes. For instance, physicians will face more scrutiny regarding the quality of care they provide.

Yet some physicians, like Stream, are enthusiastic about emerging delivery models such as Patient-Centered Medical Homes and accountable care organizations (ACOs). Both of these encourage care coordination and data-sharing among groups of physicians focused on overall patient outcomes rather than providing episodes of care. AMA President Jeremy Lazarus, a psychiatrist, says it's a promising sign that physicians are leading the majority of the first ACOs. "I think physicians see that as an opportunity to both deliver better care to their patients and have some of these additional stressors taken care of in a bigger administrative setting," he says.

Mosley says despite the uncertainty surrounding healthcare reform, new models of care, and new methods of reimbursement, it's important to remember that at least attempts at progress are being made. "I think we're heading in a direction that's good," he says. "Nobody can say if we're heading in the right direction, but we have to go in some direction, we have to start."

*To read the results of the 2012 Great American Physician Survey view our slideshow here.

In Summary

Many physicians are rethinking and reshaping their careers. Here's how and why:

• More of you favor employment over private practice due to generational shifts, increasing government regulations, and uncertainty due to healthcare reform;

• More of you seek flexible schedules due to dissatisfaction with your level of work-life balance and changing demographics;

• More of you are open to alternate models of care, such as concierge medicine, due to frustration with fee-for-service reimbursement; and

• Fewer of you would recommend medicine to your children due to uncertainty about the future.

Aubrey Westgate is an associate editor at Physicians Practice. She can be reached at aubrey.westgate@ubm.com.

This article originally appeared in the September 2012 issue of Physicians Practice.