Home > Medical/Health Commentary > Who’s afraid of the Big Bad Business of Medicine? (Part 1)

Who’s afraid of the Big Bad Business of Medicine? (Part 1)

It would appear that physicians (especially the younger ones) and medical students are, in increasing numbers

If, like me, you’re looking for interesting questions and issues relating to physician supply, orientation, and availability, this New York Times article from last month is the gift that keeps on giving.  It brings to the fore various tradeoffs and choices in the delivery of physicians’ services:  hospital-owned vs. physician-owned practices; large group vs. small group or solo medical practices; paying doctors on salary vs. paying them based on their billings[1]; co-operation vs. consolidation as ways to co-ordinate care; and of course, physicians choosing to abandon the “business” of medicine for the “practice” of medicine.

A few recent items from around the mediverse have prodded me into addressing the last issue, “clinical practice” vs. the “business of medicine.”

In the KevinMD post that I discussed on Friday, the author self-righteously proclaimed that “[w]hen [she] chose to be a salaried physician after [her] training, [she] viewed it as a natural choice to express [her] commitment to medicine. After all, [she] wanted to practice medicine, not run a business.” (emphasis added)

The Disease Management Care Blog post featured in last week’s Health Wonk Review (and its sequel) made some interesting observations about the general state of private practice, its challenges, and its trends.  It also pointed me to a few more items in the vein of the KevinMD post.

This piece looks at the issue from the perspective of small/medium-sized medical groups who are looking to hire young physicians.  We learn that there are indeed “business” concerns that affect medical practices:

“Now, if you are an owner or a partner in a practice, the business part of it becomes large depending upon your role in it,” he says. “So much has changed in healthcare with reimbursement issues and having to worry about increased costs and decreased reimbursement. There is much more of a focus on what we are allowed to do, how to code properly, how to stay in compliance with Medicare regulations, and so on. There is so much more bureaucracy and governmental intrusion and rules that we have to be cognizant about, not just practicing and winging it. You see a patient and you have to know ‘are you coding a three-level office visit or a four, and if you code a four can you prove you did that much work?’ “

However, we also learn that younger physicians don’t really want to deal with it (emphasis added):

“One of the things we are finding is that a lot of the young docs coming out of school want to go into practice and do one thing: practice,” he says. “They don’t want to deal with the business side. They don’t want to deal with governance issues. They don’t want to deal with any of those issues. So, what is happening in some of the practices we are working with, the senior docs are asking ‘what can we do to get the younger docs to get interested in the business side of the practice, the things that need to be done to keep the practice going?'”

The DMCB post also brought to my attention this amorphous lament on the alienated state of young physicians[2].  The following passages caught my eye (emphasis added):

Alienation is a state that arises from the perception that one is isolated from the established group and unable to use its resources. Certain sources of alienation are inevitable, such as the inherent difficulty of entering a new enterprise, or the explosion of diverse technologies. Other factors, not as inevitable, are even more erosive. These factors arise from the separation of physicians from the management and administration of medical care, and the all-to-often cynical exploitation of this division by financially motivated parties. This division stifles young physicians, undermines the doctor-patient relationship and disrupts the collaboration of specialists required for comprehensive medial care.

Since at least the late 1970s there has been an infatuation with the so-called “efficiency of the marketplace.” This idea has been applied as a panacea to a range of social issues, including the administration of medicine. It is central to the alienation of early career physicians.

Taking this essay face value, the sense I get is that the highlighted causes of alienation are probably exacerbated by, if not caused by, an unfamiliarity with, or lack of willingness to confront, the business side of medicine[3].

One could ask if this trend in preferences is necessarily a bad thing.  After all, aren’t physicians terrible businesspeople to begin with?  Do we even want our physicians to sully themselves with the sordid business of… well, business, lest it affect their clinical decision-making?  Shouldn’t the business side of medicine be left to businesspeople and administrators?

As I’ll argue in Part Two (soon to come!), it’s not that simple.


[1]See the preceding post for a more in-depth discussion of this issue.  The first footnote there explains the distinction between physician billing and physician payment.  Back to text.

[2] – The author’s definition of a “young” physician is one who is under the age of 40 and has been practicing for less than five years.  Now, I know that 60 is the new 40 and whatnot, but as someone entering medical school this year at the age of 22… yeah.  Back to text.

[3] – While there’s plenty to be said about inefficiencies and market failures in the market for physicians’ services, one partial efficiency is the way the market, through the outcomes of consumer choice, forces medical groups to take at least some non-clinical actions to attract and retain patients.  The MD degree doesn’t come with a guaranteed client base.  Back to text.


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