This week I learned that my primary care physician, a young enthusiastic doctor with an interest in whole patient care, had finally succumbed to the clutches of Rochester Regional Health System. Like 60% of his peers, 50% of surgeons, and 25% of surgical sub specialists he has finally become an employee of the health system.

It’s a decision I understand. Running a private practice leaves room for little quality of life as mounds of paperwork, endless problems with insurance, staff issues, and outright bureaucracy conspire to choke entrepreneurial providers. Moving to a salary based system offers greater security, the potential for some personal time, and a chance to focus on medicine.

Yet, it isn’t all wine and roses. While salaries may be fixed for the first three years, there is invariably a performance component that comes into play later, and one author found that newly hired PCPs must generate at least 30% more visits than they do at the outset for them to pay their way. Primary care practitioners have historically been a loss leader for hospitals, and to justify the salaries in the longer term, they must generate business.

From the patient’s perspective there are benefits such as access to a greater set of resources, physician assistants, nurses, and other medical professionals that are provided through the healthcare system. The healthcare IT systems tend to be more robust than those used in practices, and this can lead to the benefit of not having to repeat information endlessly to new providers. Patients who are on Medicare and Medicaid may now be more palatable as there is more financial free play to wait for claims to be paid. In short, working with a larger entity has its benefits.

While it’s nice to think there won’t be many changes in the way that he treats his patients, the reality is that patients who require longer visits may find the time curtailed, because the health system will be looking for a minimum throughput rate. He is also likely to find himself referring more in network, and many of the specialists whom he has grown to trust over the years, who do not participate in that network, may see fewer of his patients. That’s just part of working for a corporation, an entity which is fundamentally about balancing the books, and staying afloat.

While I’m certainly going to miss our long meandering conversations, I understand the pressures which he faces, and the odds which are against him. He can choose to become a creature nearing extinction, the medical Tasmanian tiger, or he can make a sensible financial decision and join the modern world. After all, it was unlikely that he would be able to keep going for long.

I recently re-read Cronin’s book, “The Citadel”, an account of the young Welsh doctor who starts his professional life as an assistant working for a health board, progresses into private practice, chases money and social standing, and finally through the death of his wife comes back to his roots in medicine as science.

Cronin’s message embraces a multitude of caregivers, an integrative approach, and the idea that the doctor as an entrepreneur should not be conflated with care.  It remains timely in this day and age, as many practitioners move from being proprietors of business, into being employees of larger corporations.

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