Fifty years ago, medical graduates’ licensing required membership in the AMA, the state, and the local county societies known as organized medicine (OM). Physicians, through their OM, wrote the rules and guidelines of the practice of medicine, controlled the hospitals through their medical staff organizations, and jointly approved what health insurance covered with the insurance carriers.
In the last 40 years, gradual changes in our country have affected our patients and us and deeply altered the delivery of medical care. As physicians, we have transitioned from being leaders to being followers in the face of these changing winds of “dis-reform.” This has left many currently practicing physicians feeling powerless, burned out, frustrated, and subdued by the realities of new entities, companies, laws, and regulations.
The most significant impact is the “decomposition” of the sacred patient-physician relationship due to the profit-first goal of corporate medicine. Despite the rising cost of medical education and increasing competition for medical school slots, physician income has remained flat and eroded by inflation. Meanwhile, revenues from hospitals, insurance companies, and providers of care are alarmingly increasing.
In the last 20 years, medical graduates have had to borrow more money to pay for tuition and living expenses. Their post-graduate salaries are modest, considering their education, skills, and long working hours. Upon completing their training, they often seek the easiest and highest income rather than the best future practice setting or income. Buying a house, starting a family, and repaying student loans are their biggest challenges, making hospital employment appealing over starting a private practice, which seems too complicated and costly. Joining a group of independent practitioners (IPs) initially provides a less competitive income, but they may need to realize the priceless future earnings, equity, and independence they can gain.
Numerous specialty societies have emerged to meet the need for leadership among physicians in various specialties, but this has resulted in a fragmented medicine that weakens the influence of organized medicine and major specialty societies. Even in a small specialty like plastic surgery, one can find more than a dozen subspecialty groups. The multiple, often expensive annual dues for these organizations make it difficult for physicians to join the more influential and effective organized medical societies (OM).
With the formation of large hospital networks, the restrictive non-compete clauses employed physicians (EPs) are required to sign make it difficult, even in large metropolitan areas, to find a new practice location for unhappy EPs. Hospitals’ initial contracts may be generous, but subsequent ones may not be as appealing. Hospital employment may not be ideal for many physicians as their health plan coverage is usually limited to the integrated “providers” within the system. Additionally, there may be an unspoken commitment to inter-referral within the system, which prohibits referring patients and loved ones to the best care available in the community or outside of it. The extended providers within a particular hospital system may not necessarily follow the EPs’ care strategies or vision of care.
Employed physicians are less likely to join organized medicine, as their employers may only allow a limited sum of money, if any, for membership dues. They often join one or more of their specialty or subspecialty societies first, as they are familiar with these organizations and receive newsletters and electronic communications during training. It is only when they need help to protect themselves and their patients from threats, such as employers, lawyers, regulators, insurance companies, or others, that they realize the need for OM.
Legislators at all levels of government rely heavily on lobbyists to draft and support their bills. They cannot consult with every specialty and invite them to their hearings. Instead, they mainly rely on OM lobbyists for those purposes. No one can ignore the contributions’ role in these processes. Large membership means more money and bigger leverage. Suppose all physicians had joined their respective OMs, as hospitals have joined the AHA or the attorneys, the ABA. In that case, we could not have experienced most of the unfriendly and distracting changes that led to the loss of control and the erosion of the patient-doctor relationship.
Edmond Cabbabe is a plastic surgeon.
