Control, Contracts, and the Truth About Physician Stability

In this episode of From Print to Pod, we host a discussion based on the article The Stability Many Physicians Assume They Have.

In the medical field, many physicians enter practice believing they have a stable career ahead of them. However, recent discussions highlight a different reality. In this episode, we will explore the insights shared by Dr. Marcelo Hochman and panelists Hochman, Hooks, and O'Leary, on job security in medicine, the importance of autonomy, and how to navigate a changing healthcare landscape.

SUBSCRIBE TO OUR PODCAST → https://www.doctorsonsocialmedia.com/podcast

FIND AN EXPERT IN OUR DIRECTORIES → https://www.doctorsonsocialmedia.com/directories

Participants:

https://doctorsonsocialmedia.com/marcelo-hochman-md/

https://doctorsonsocialmedia.com/bertina-marie-hooks-md/

https://doctorsonsocialmedia.com/james-oleary-md/

Takeaways:

1. Assess Alignment: Physicians should regularly evaluate whether their practice aligns with their personal values and career goals.
2. Seek Autonomy: Exploring independent practice options can lead to greater job satisfaction and fulfillment.
3. Recognize Value: Physicians must understand their worth and the skills they bring to the healthcare table.

Doctorsonsocialmedia.com, or SoMeDocs for short, is a healthcare omnimedia platform committed to promoting autonomy for the individuals in healthcare. Subscribe to our newsletter to not miss our new articles, episodes, or events: https://doctorsonsocialmedia.com/subscribe. Contact us anytime, at somedocs@somedocs.com  (please note that we receive many emails and may not respond to all).

Transcript

Dana Corriel (00:08.982)
Welcome to our second season of From Print to Pod. I am so excited and honored to have three new panelists here to discuss the article that Dr. Marcelo Hochman has written. The name of the title of the article is, The Stability Many Physicians Assume They Have. And Dr. Hochman happens to be here with us. I am going to, as always, go around and ask questions. And with the first question, I'm going to have each of you also introduce yourselves. So let's get right to it. The first question is, when did you first start realizing that your job might not be as secure as it seemed? And so let's start with the author of the article, Dr. Hochman and don't forget to introduce yourself with your reply.

Marcelo Hochman (00:57.302)

My name is Marcelo Hochman. I’m a facial plastic and reconstructive surgeon in private practice. I spent 10 years in academic medicine full time, and I’ve been in private practice since, while still maintaining an affiliation with the academic center. The point at which I realized I needed to do something different came when I looked at the priorities I had for building the type of practice I wanted and compared them with departmental and institutional priorities. In that moment, it became clear that mine were never going to happen. I decided to leave, opened a practice from scratch, and structured my priorities in the order that I wanted.

Dana Corriel (01:44.716)
Thank you for that. Dr. Hooks, when did you first realize your job might not be as secure as it seemed? And don't forget to introduce yourself.

Bertina Hooks (01:53.836)
Yes, thank you, Dana. My name is Dr. Bertina Hooks. I'm a board certified internal medicine hospitalist. practice for over 15 years. Now I currently work a hybrid role where I do clinical work and non-clinical as a utilization management medical director and a medical expert. And as far as similar to Dr. Hochman,

When I was about five or six years into my career, I realized that my values weren't really aligned with the current role I was doing as a hospitalist. And I realized that I wanted to kind of practice on my own terms. So like Dr. Hochman, I did leave hospitalist medicine and started my own.

primary practice. I also did a locums practice for years. It had like a locums agency wide facilitated my own locums assignments. And that gave me more freedom and autonomy and to research and kind of explore the different options that physicians have. And so that led me to pursuing medical expert work later on and utilization management. And I feel like that hybrid is a good fit for me because it allows me to practice on my own terms, expand my medical knowledge and scope, and make an impact to more patients on a larger scale.

Dana Corriel (03:33.226)
Very good. Thank you for sharing that and welcome to the show. Dr. O'Leary reading the question again. When did you first realize your job might not be as secure as it seemed? And don't forget to introduce yourself.

Jim O'Leary (03:45.294)
Thank you, Dana. My name is Dr. Jim O'Leary. I'm a retired OB-GYN. And my experience right at kidney realization was pretty much right out of the chute. Got out of residency, went to my first job, and like everybody coming out the first job, you don't know what you don't know. So I went into this multi-specialty clinic and they had just merged with the hospital. And I didn't really understand what that meant. So I was there for about 10 months in, and then all of a sudden the hospital's coming by, they're micromanaging everything. And my partners were much older than me. They're in their mid 50s. They were kind of griping, but they're like, well, we're from here. We're not going to do anything. They're just going to put up with it. And I just came home and I looked at my poor wife. I said, we're out of here. I have to find some other job. But it was really great because then I was like, OK, I want to join a single specialty clinic that's private practice. I never want to be in that. So I really focused what I needed. And it was early on. And it was actually clinically a great place to work. It was in Fargo, North Dakota.

And the amount of subspecialty care that I did was unbelievable. And when I actually did it in my boards, I know this is off script, I had my boards list and they're like, why do you have all these oncology cases and high-risk OB cases? I'm like, cause I'm in North Dakota, we have no subspecialists. They're like, my God. So it was a great experience. you know, I just, took my lungs early on, moved on and enjoyed what I did after.

Dana Corriel (05:09.762)
Fantastic, and we'd love Offscript just as an FYI. All right. Dr. Hogman, let's move on to the next question we'll ask you first. Looking back, was there one early decision that ended up shaping your career more than you expected?

Marcelo Hochman (05:26.69)
I think it was what I just mentioned before was I did my residency, did two fellowships, landed in my first job, was extraordinarily busy, just loved it, honestly. I clinically, I was doing so much and growing and learning and, you know, was the head of the division, all these things until...

Again, I got to a point of one portion of my practice that I felt like I needed to develop both for the residency program and for my own. And that's when I realized that structurally, the practice that I was in was one that I really had no leverage over. And then my personal priorities were just not aligned. That buzzword alignment were just not aligned with the department. They weren't bad ideas and they weren't not.

You know, the system wasn't really, you know, at fault. It's just they didn't match. That's the point where I realized that it took me two years where I realized that the loyalty that physicians exhibit towards the organization is far greater than the loyalty exhibited by the organization to the physician. So had they wanted me gone, it would have taken about one meeting in 30 seconds and I would have been gone. For me, it took me two years of realizing all of this, but I think that was the moment. For me, it was just realizing what kind of practice and medicine do I want to have and what do I have control over? And when I realized that, I switched gears.

Dana Corriel (07:08.364)
That's powerful. I'm actually going to throw a follow-up question your way, a quick one. Do you think it's different for you being a plastic surgeon as it would be, let's say, for an internist like myself and Dr. Hooks?

Marcelo Hochman (07:20.92)
That's a great question because it's really relevant nowadays. And the thing that has changed, I think, dramatically is that in training programs, and I'm affiliated with the training program, the residents come through my office. And yes, plastics has some things that address what I'm going to mention. Most specialties, in my experience, the residents, the fellows are no longer exposed to the independent practice of medicine. So all their mentors are basically growing up in the system. So when it comes down to them deciding what they want to do, they really don't have a lot of people to turn to unless they on their own seek it out outside of the system. And that has become a real problem, I think, because it's generating generations of physicians that, as Dr. O'Leary mentioned early on, they don't know what they don't know.

So all of a sudden, whether you're plastics or pediatrics or internal medicine or whatever, if you don't know that it is even an option to go do this, they just assume they have to go and get employed.

Dana Corriel (08:33.176)
Thank you. Really speaks to me with Somi Docs because that's part of what we're trying to do is really create resources that students everywhere and trainees can access and learn from. Doctors just like are here on the panel. Okay, let's move on to Dr. Hooks and I'm going to read the question again. Looking back, was there one early decision that ended up shaping your career more than you expected?

Bertina Hooks (08:56.862)
Yes, I would say that for me, similar to the other doctors on this panel, while I was starting my early career as an attending, as a hospitalist, I realized that there was other options. I was an employed hospitalist for a big HMO and I loved my job. But at the time when I decided to transition into locums in my own practice, the administration wasn't very supportive. They felt that we were expendable as employees. And so we were asking for raises and other accommodations for our job because we provided excellent care as a group, limited adverse outcomes for patients. And the specialists that we worked with were very pleased with the care that we provided and we were very responsive and everything.

So we felt that, you know, that was justified to ask for those certain things, but that kind of fell out, fell on deaf ears, so to speak. And so as a result, I really started to question, you know, my role in medicine and wanted to really practice medicine on my own terms. So I started doing locums. And I think that was really a pivotal moment because really as a locums physician, you really start to understand that you are the commodity.

Your skills, your expertise can be utilized in different ways. And so you start to have a lot more autonomy, flexibility, and that really changed my view of how I wanted to practice medicine. When I came out of residency, I actually felt like I was going to practice clinically, you know, for an employed entity for the rest of my life. But that experience doing locums full time for over six years, starting my own agency, starting my own practice, really was a pivot for me to start thinking about my skillset and change my mindset on how I wanted to practice medicine.

Dana Corriel (11:10.178)
I think so many physicians are pioneering that sort of like autonomous work and autonomous career now. And so I really respect that. Quick follow-up question, are you happier now?

Bertina Hooks (11:23.116)
Yes, much happier because I think that my role now is aligned with my values and how I want to practice medicine, how I want to show up for patients, whether it be in utilization management, medical expert work, or clinical work, I really feel like the variety, that multifacetedness is really important for me.

Dana Corriel (11:44.002)
Fantastic. Thank you for that. Now we're going to move on to Dr. O'Leary. I'm going to repeat the question. Looking back, was there one early decision that ended up shaping your career more than you expected?

Jim O'Leary (11:55.246)
for two etchings, I'm an off script kind of guy. So when I joined this practice, there was two hospitals and I was kind of the pioneer for a group. They're going to put me into this kind of network satellite hospital. I went down there and the physicians there, the independent physicians there were great mentors. Now this gets back to what Dr. Hochman was saying. You know, I was a young guy. These guys were in their fifties. These guys were hard asses, if I can say that, but they were really great clinicians, but they really wanted to be independent. They wanted the ORs to run well, and I respected them so much. I really allied with them. The rest of my group was totally different. And I was like, you know what? I'm going with these guys. You know, it worked out well. The second thing I did was there was some quality issues in OB-GYN at the hospital, and they quickly said, you know what? You're not from here. And this happens at every hospital. There's two or three competing groups. And then, you know, if you're a troubled physician, you say, well, they're picking on me because they're in a different group. Well, they said, you just got here and you don't know anybody. So we're to have you start reviewing the records. And I really enjoyed doing that. I did peer review for decades there and I became known as kind of the go-to guy in my specialty. If the nurses had problems on the floor, saying, you know, we're in problems with postpartum hemorrhage. Will you work with us? Come up with protocols, get it instituted. And they knew I'd always do what was clinically needed. So on one hand, I was pushed into the hospital saying,

I wanted to remain independent. On the other hand, I was helping them out clinically where I could and kind of gathering friends at the same time. So it was good because I realized early on we have to deal with the hospitals. They have a lot of power. And if you irritate them, they can make your life pretty miserable. So I was trying to straddle the fence a little bit, irritate them a little bit on the independence part, but help them out tremendously clinically and work closely with the staff.

Dana Corriel (13:43.426)
Thank you for that quick follow up question. Would you describe some employers out there as bullies?

Jim O'Leary (13:53.644)
Yes, 100%. And I think that, and I saw that at hospital I worked at, they wanted control more than anything. And sometimes the control was more important to them than financial considerations. There was a orthopedic surgeon there who was fellowship trained, and this is going back into the 90s, in joint replacement, in a huge number of joint replacements, brought in huge amounts of money to the hospital. All he asked was he wanted to choose what implants he would put on there, and he didn't want to be on trauma call.

And very reasonable guy, one of the nicest guys ever. And literally they could not leave this man alone. So he quietly went to a competing hospital down across town. He didn't get mad. He just said, well, this is how I'm going to practice. And he left. And it was amazing. I mean, they just lost millions of dollars because some low level executive wanted control over this man. It's crazy.

Dana Corriel (17:19.994)
Thank you for sharing that. Okay, we're going to move on to the next question. Do you think that most doctors understand how much control they really have at work or do they find out later? We're going to vary up the order here just to keep it exciting. Dr. Hooks, if you can go ahead and answer that, that would be great.

Bertina Hooks (17:41.07)
I think, unfortunately, no. think most physicians don't realize how much power that they have. I think they underestimate their skill set, what they bring to the table. And I think that's why sometimes they accept, you know, lower than they deserve in terms of compensation or benefits or other things. And it's more, or even their call schedule, you know, things like that, things that are easily negotiable. And I think as being a locums doctor for so long, I started to learn that nuance, that dance of contract negotiation and really advocating for myself and also helping other physicians learn how to advocate for themselves. I'll give you an example. I was doing a locums assignment. I lived and practiced in California for over six years. And during that time, I worked throughout the California area. And so there was a younger, early attending that was accepting a pay rate that was equivalent to a physician assistant or nurse practitioner. And they were a recent graduate. And so we had a discussion and I started to tell them that you need to know your worth. You need to understand the, you know,

No one can do your job but you. The recruiter can't do it. The hospital administrators can't do it. Only you as the physician can provide those patient services. And so you have to know how to market yourself for lack of a better term of what you bring to the table and really have some, I guess, boundaries in terms of what you will accept and what you won't accept, what is sustainable and what isn't. I mean, because in any field, especially medicine, you can be burned out quickly. And so you really have to structure your practice to sustain you.

Dana Corriel (19:41.326)
Thank you for that, Dr. Hochman?

Marcelo Hochman (19:44.982)
So the way I look at it is that it's really more from a structural lens. So all the things that Dr. Hook said and Dr. Lear said and that I say, those are all true. But if you are in an employed setting, you have a boss, an organization that has defined goals and agendas and this and that.

And I think that that's where physicians start getting frustrated is because they think, I'm worth this. I'm worth that. I'm doing this. am the, when you are working for somebody else, those agendas take priority. So it is, I think a structural thing. is the contracts, you know, the things that they're looking for are so far out of the clinical sphere, which is where the physician is really centered that that's where the conflict comes in or the moral injury that people say, I was doing things that I didn't believe in or my values didn't align. But it's really not because it's a good and bad sort of dynamic. It's just that it is structurally a different thing. And for medicine, I don't think it works as well. And that's why you see so many people trying both things and end up being much more happy when they have autonomy and flexibility and some of the other adjectives that people have mentioned today. So I think it's a structural problem, not a values, I'm right, you're wrong, or even legally. So I've been involved in our state in repealing the certificate of need laws and non-compete laws and those kinds of things. They're structural problems and physicians have a choice. Do you want to work within those guidelines or not?

Dana Corriel (21:41.038)
Dr. O'Leary, I'm going to repeat the question just because you're third this time around. Do you think most doctors understand how much control they really have at work or do they find out later?

Jim O'Leary (21:53.89)
I'm gonna actually reject the premise of this. I don't think we have control at work because as an individual, and Alysia, very specific, if you're a GYN oncologist and they could recruit one for two years, you come in, you've got power. But if you're a GYN, you're an internist, you're one of, I'll just say one of 10. You don't on your own have a lot of power. However, we have all the power if we work together. And that's what's frustrating to all of us here is that physicians don't realize that we think we're powerless. We complain about it. We have all the power. We just have to take the power and we you know, that's what I think is the beauty of so many docs. That's why I love so many docs. That's why I love getting on social media because all of a sudden people are like, wait a minute. I'm not the only one who's frustrated. I'm not the only one who thinks this way because all my partners tell me I'm crazy. The hospitals like well, it doesn't matter what you think.

So I think that's where we have to go. And I think we have to really work with young physicians because, I, the big thing I think docs don't understand is, and the primary care guys are starting to see it, is there's a tremendous need for our services. And there's always people willing to pay for it and we're undervaluing ourselves. Now you're seeing the DPC movement where they said, hey, I can go out and I can open things up. And, but I think docs are very risk adverse.

And that's kind of in our nature. That's what we do all day. We try to manage risk. so I think we're missing the task, but I think it's hard to do it as one of one. I think you can't be the army of one and change it in most scenarios. And I agree with Dr. Hochman. If you're employed and you've got a really adverse contract, you're kind of stuck. You can say, well, I'm going to leave tomorrow and I'm going to open up my shingle across the street. And then you have a non-copete. And if you're in Florida, that's not going to work.

So I think we have to really work together. So we've got to really support each other.

Dana Corriel (23:50.21)
Totally agree. And we have a private practice community that's popping up in SoMeDocs. We already have a ton of resources. So I'm excited. We're also hosting the third annual private practice online event. Let's move on to the next question. What's something about working in big health care systems that doctors don't fully realize until later? Let's start with Dr. O'Leary on this one.

Jim O'Leary (25:45.922)
You don't realize till later that they're gonna control you. And you don't realize that it's incremental. It's kind of quiet in the beginning. They're welcoming. They talk a good game. They bring you around. meet a couple executives maybe. But slowly, but over time, they start limiting your clinical decisions. And they ultimately say, well, it's up to you. But then they put handcuffs on you. And I've had frank discussions with them because I've done a little, you know, locum's work and hospitalist work, you know, towards the end of my career. And I was like, this isn't how this works. And, but you know, if you're starting out, it's very intimidating. And the game is that they really put all the risk on our shoulders. They say, well, you're the one making the decision and they give you all the incentives to make the wrong decision. And they push you and they punish you if you don't make the wrong decision. So it's, very underhanded. So you really don't have the power.

That's what I think people don't see till later. And I think that's why people get burned out. They get frustrated. And I think it's destroying healthcare, these big systems. And I'm gonna send this here. If physicians can't own hospitals, hospitals should not own physicians. Full stop.

Dana Corriel (29:15.096)
Thank you for that. Dr. Hochman, what's something about working in big healthcare systems that doctors don't fully realize until later?

Marcelo Hochman (29:23.416)
Well, I think it's a combination of all those things. think the bottom line is the agenda. I mean, I now have employees, right? I have a staff and I have an agenda for my practice. And it's the same thing with the hospital systems. The underlying root thing that I think we need to address, which I'm very interested in, involved in now is educating medical students and residents and fellows in, as Dr. Hooks mentioned, literally the business of medicine. We need to treat or teach physicians in training, give them information so that they have options. think maintaining optionality is key. Now, you may choose to be employed and there's nothing wrong with that, but you can also negotiate things ahead of time. You know, if you know that you can do that. Oftentimes, a fellow really comes out and just signs the contract because it's their first job and all of a sudden, five years later, they find themselves with a surprise that was not a surprise to anybody but to them. So I think recognizing that there are different agendas, again, not good, not bad, they just are what they are, having the information to make decisions early on sort of plan, be honest about what you think you want your medical career to be like. And sometimes you really don't know. You can only do a little bit at a time. But if you constantly re-evaluate the decisions, you know, I mentioned in the article that poly is earned, you know, which to me is so, it visually describes what happens and how this decision eventually

Five years later, you say, how did I get here? Well, if you actually look back, each decision reinforced the other one and the other one and the other one. And all of a sudden, my gosh, look where I am. So anyway, I agree with basically most everything that's been said. It's a matter of realizing what your role in that organization is. Are you the owner and set the agenda? Are you a co-owner and participate in the agenda? Are you an employee? And you don't have much leverage in that situation.

Dana Corriel (31:48.628)
It couldn't be any more clear than that. So with this, let's come to the next and final question. It was actually a question that was suggested by Dr. O'Leary. So I'm going to have him go first in answering it. But I think it's a really clever one because it almost like turns things around and makes us think about the following. Okay. What are the reasons that physicians either leave private practice to become employed? So the opposite of what we're talking about, or choose to only consider employed positions. Now let's start with Dr. O'Leary.

Jim O'Leary (32:25.166)
When I moved to Florida, I was fascinated because all of the specialists were employed. And I was talking about like, what are you guys doing? Why are you doing that? And they told me there's two reasons. They said they really had trouble getting good contracts, good reimbursement, and the hassles were the electronic health records. But I did look at groups, like there is a group of maternal fetal medicine specialists in the area. They have one group that control the whole market. They should not be employed. They should be able to hire managers to sort out these issues for them, but they're still doing it. So was really fascinating to me. It was just like a cultural issue here. So that's what kind of drove that in my mind. Why would people do that? And I think it just was, you know, Dr. Hochman was saying, and Dr. Hooks was saying that the residents, the students don't even know anymore that there's different options. They're just like, they see everybody come out of training and they become employed. You're like, well, let's just get the job here and be with our buddies and this'll be great.

You know, that's where I think so. I think we really have to set that standard for people that, you know, address it head on why these things are made. The decisions are made and make sure if people are going to be employed, make sure they're doing it for the right reasons. I agree. There's great reasons to be employed. Many people enjoy it and that's wonderful, but just don't do it because you don't know you have any other options. And the only other thing I would say is take your contract, feed it through ChatGPT or your favorite AI and say, read this as an employment attorney and tell me what are the adverse parts that are gonna affect me as the employee. There's no reason not to do that.

Dana Corriel (34:03.948)
Great advice. Okay, Dr. Hooks, same question.

Bertina Hooks (34:09.336)
So I would say that there's nothing wrong with being an employed physician. I was an employed physician for many years before I started my own practice and became an independent contractor as well. I think that there's safety, know, predictability with being employed, which a lot of physicians gravitate towards. It's kind of the structure and the culture that we know. But one thing that I'm doing, I work with the SNMA and AMSA groups. I do a lot of education. I just did a talk on March 21st with future physicians about this issue. And it really is about clarifying your identity. I think understanding that your role can be more and that your medical degree has transferable skills that can be used in different areas, not just in clinical medicine. And I think that being open to those opportunities, those possibilities is very important. And I think that employed models work in lots of different ways. I mean, I don't think the employed model will go away, but there's also room for other types of models too. And I think it's important to explore that and see which one is the right fit for you. I think understanding the business side of medicine, understanding those different opportunities out there and exploring them, doing informational interviews with people in different industries, talking with having mentors that can help you with that is very important. And so I would say that the employed model, there's nothing wrong with getting your feet wet, getting comfortable with practicing medicine after you finish your training, but it's important to explore other options if the employed model doesn't work for you.

Dana Corriel (36:03.992)
Thank you for that. Dr. Hochman, same question.

Marcelo Hochman (36:07.47)
So nationally, we know the answer to those questions. We know that the physicians have migrated towards employment because of some of the things that have already been mentioned. Way up there are financial considerations. Practices feel like they can't make it because they're tied to these assumptions that you can only do it with third-party payments and all that. And we know that there are other options, DPC and a lot of other ways to run a pediatrics practice if you wanted to.

So financial considerations, the administrative burden of EMRs and all the regulations where, now you have, you know, five, six non-clinical people supporting each clinical position in an office gets burdensome, you know. So people say, well, I'll just let the hospital take care of those things. There's a price to that. So I think the reasons why people gravitate to employment

sort of not thinking that that's what they wanted to do in the first place are these external things. Now, for some people, it really may be a great choice, right? I mean, there are a lot of reasons why being employed at an academic medical center or a VA, I mean, there people that that would be a great source of professional enjoyment and all that. I think the root thing though is what we've all touched on is that

trainees are not getting exposed enough to the options. used to be that was the norm. The OB-GYN resident rotated through an OB-GYN practice, you know, and spent time. When I was a resident at Stanford, there was a surgery ward, a service that was private practice. People wanted to come to that hospital.

and the private physicians would bring their patients here. That hardly exists anywhere anymore. So education starting to reintroduce the idea at the medical school and residency level that real stability in your future practice comes from understanding what your position is going to be in whatever structure you end up in, you know? And then keeping your options open consciously, not just like, didn't realize I had a non-compete. So anyway, those are the things that I think about.

Dana Corriel (38:39.416)
Thank you. And a reminder to the audience that Dr. Hochman is the author of the article that we based this podcast episode on. The title is The Stability Many Physicians Assume They Have. With that, we're going to close this episode up. I want to thank each and every one of you for giving us your time and your wise insight. And join us next time for another episode of From Print to Pod.