Four years ago, I (JEL) had just finished a fellowship and was elated to start my dream job in a physician-owned and operated group practice. The doctors in the group were tight-knit supporters of each other and the local community. Right away, I began building meaningful relationships with the patients and colleagues that I thought would be with me for decades. But without warning, in year two, the group’s senior partners sold the practice to a private equity (PE) firm. Practice leadership insisted the deal would benefit doctors and patients alike and reassured clinicians that our daily practice would not change.
As promised, clinic operations continued as before, but soon my patients reported bigger bills for their visits and noted that it was impossible to reach me with our new phone system. More significantly, the private equity deal coincided with my first contract renewal. I was offered a 20 percent lower salary and a non-compete clause with a radius of 100 miles for two years. I was floored. It felt like the caring, collegial group I joined had vanished.
I am a rheumatologist, and many of my patients have complex illnesses. Much of what I relish about being a doctor is connecting with patients, drawing out their stories, and using a hypothesis-driven, nuanced elicitation of the history to solve their medical mysteries. Now, instead, I was frequently distracted by more base considerations about whether my salary would cover child care costs; making contingencies to move out of state should the practice become intolerable and whether I would know when it was time to leave; and the sense that my new employer’s interests did not align with my patients’ or my own.
Worse still, I was sure speaking up would cost me my job. How did I end up in a corporate environment I barely recognized as medicine?
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Fifty years ago, I (KMP) began my career as an attending physician at a large academic medical center, where I still work today. Like so many of my colleagues, I entered into the practice of medicine with the goal of answering to a higher calling, namely the humanistic, compassionate care of patients. Indeed, a physician’s priority was to his or her patients, even if it meant sacrificing time for yourself or with family.
Over my half-century of practice, health care evolved from primarily small businesses (private practices) into complex, highly consolidated systems jockeying for regional, national, or even international market share. Those goliaths squeezed small practices out of insurance contracts and excluded them from narrow networks, ensuring they would eventually fail and reduce competition. Now, most U.S. physicians are employed by hospitals, large group practices, private equity-backed staffing companies, or managed care consortiums, and physician remuneration is complicated by onerous rules of coding and documentation. Most critically, metrics purporting to measure physician effectiveness—tied to an institution’s financial goals and therefore, slavishly followed—undermine physician autonomy.
I enjoy the luxury of maintaining decades-old practice patterns by dint of my senior position and long tenure at the university. I spend ample time with patients in the hospital and clinic and speak directly with referring physicians about their complex patients. But my younger colleagues have no such privilege. They are pulled away from their patient’s bedside or from conversations with colleagues by the relentless intrusion of the electronic medical record and ever-growing demands for “productivity.” I am awed by the exponential progress in medicine’s power to cure and to palliate over the past half-century, but was the cost to physicians and their patients inevitable?
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Uncertainty, workflow disruption, and rapid organizational changes accompany health care mergers. They also disrupt relationships as people scramble to understand the dynamics of the new organization. Physicians feel less positive about their collaboration with colleagues, less safe and supported, and less inspired to go above and beyond in their work. The culmination of these added strains has been called burnout for decades and has proved stubbornly resistant to varied interventions. One study reported burnout increased from 45.5 percent in 2011 to 54.4 percent in 2014, and to a staggering 63 percent in 2021 amidst coronavirus challenges.
Many clinicians, though, have long argued that “burnout” fails to capture a critical aspect of their distress: that the patient-first values of their Hippocratic oath are threatened by the business imperatives of our burgeoning health care systems. Moral injury is a betrayal by a legitimate authority in a high-stakes situation, which causes one to transgress one’s deeply held beliefs and expectations. In health care, those beliefs are the promises we made, reinforced throughout our education and training, to put patients as our priority, setting aside personal or organizational self-interest.
Corporatized health care, though, regularly confronts physicians with obstacles that include an element of potential transgression. Clumsy and inefficient electronic health records are designed to maximize organizational self-interest (billing and safeguarding competitive advantage) rather than optimally facilitating care. Staffing levels meet financial targets but risk patient safety. The expectation to see yet more patients in ever less time invites errors. Perverse incentives and employed status routinely lead to treatment decisions fraught with moral challenges between the physician’s professional obligation to the patient and their obligations, as an employee, to their institution. And the 80 percent of physicians whose practices consolidate without their input—decreasing competition, raising prices, constraining physicians’ options for where and how to provide clinical care—ultimately see worse outcomes for patients.
When we don the mantel of “physician,” we put our patients’ needs as our top priority and set our own self-interest aside. We have been slow to speak out, refusing to believe this stance was anything but self-evident and worried about retaliation. But our patients and our profession have suffered from that reticence. It is time to strenuously defend the sanctity of the doctor-patient relationship, the foundations of trust in our profession, and the value of the expertise we earned with study, sweat, and sacrifice in the service of our patients. We should no longer remain silent.
Jason E. Liebowitz is a rheumatologist. Kenneth M. Prager is an internal medicine physician. Wendy Dean is a psychiatrist.
