Surviving the transition from independent physician to employed

Robert Bailey, MD, had been in private practice for almost 15 years when he was recruited to lead a urology division in the employed physicians group owned by Phoenix Children’s Hospital in Arizona in 2011. Although he might not have entertained the idea a decade earlier, Bailey decided that joining a larger system made sense from both a clinical and financial perspective.

Like Bailey, many physicians see employment with a medical group or hospital as a way to escape the administrative burdens of running a private practice. Surveys show a steady migration away from independent practice as physicians grapple with new delivery models and more complicated billing and coding requirements-on top of the everyday concerns of running a small business (see sidebar, “An Exodus From Private Practice.”)

While moving to a hospital or health system eliminates those burdens, physicians should count on making a few trade-offs, according to their peers and hiring executives. In exchange for more financial security and freedom from paperwork, physicians must accept less control over the way they practice medicine. The key is going in with open eyes, having made a conscious decision to give up some things in exchange for others that are more important to overall job satisfaction. 

“Physicians who were partners in a practice and used to making their own decisions face the biggest challenges when they become employees,” says Tommy Bohannon, vice president of sales operations at Merritt Hawkins, a Dallas, Texas-based national healthcare search and consulting firm. “They may no longer have a say in who to hire, what hours the clinic is open, or what hours they work-that’s the biggest adjustment for many.”

Even when physicians are cognizant of those trade-offs, they might underestimate the difficulty of switching from an entrepreneurial to a corporate culture, says Gail Gazelle, MD, a physician career coach and an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts.

“One of my clients thought he had his dream job but he hadn’t thought it through,” says Gazelle. “When he found out how stifling the corporate culture was at his new job, with very little room for creativity or input on how many patients he would see, he was in a state of shock.”

Finding the right fit

Taking some time to find the right fit can help minimize the culture shock that some physicians experience. Experts advise performing due diligence in the months leading up to accepting and starting a new job in order to vet prospective employers and weigh the pros and cons of different options.

The key to happiness as an employee is going into the job with realistic expectations, says Allan Cacanindin, senior vice president at physician recruitment firm
Cejka Search, based in St. Louis, Missouri.  He recommends connecting with physicians who already work at the organization. 

Ask them about the work environment, whether they feel restricted in the way they deliver care, and how productivity-based bonus structures have affected their income, he says. Get a sense of what it’s like to work as part of a care team and how that might affect your interactions with patients. “For many physicians, the concept of sharing the care of their patients and developing relationships as a team is new,” notes Cacanindin.

The prospect of losing control or “being asked to practice in a way that doesn’t meet their own moral compass,” is the biggest fear for many physicians when they contemplate leaving private practice, says Gazelle. 

For example, while there’s pressure to stay on schedule in private practice, physicians generally make their own decisions about how much time to spend with individual patients, she says. As employees, however, their every decision may be recorded on a computerized dashboard where the entire team can see how far behind they are, how many charts are still open, or how many patient messages are in their inbox.

For many physicians that kind of accountability seems like a reasonable trade-off for having a more stable income and better work-life balance, notes Bob Collins, managing partner in charge of physician recruitment for The Medicus Firm, based in Dallas, Texas. 

A larger company might offer more income and career advancement potential, whereas a smaller employer might pay less but offer physicians more control over their day-to-day practice, such as scheduling, staffing, and time spent with patients.

“Physicians have to be comfortable with the framework they’re entering into knowing that there will be give and take in any situation,” says Collins. “Your ability to influence change in a large organization is likely to be minimal because the larger the company, the more likely they are to need standard processes and procedures to operate efficiently.”

As an employer, John Hamilton, senior vice president and chief operating officer of Phoenix Children’s Medical Group, believes in confronting physicians’ concerns head-on during hiring negotiations. He urges prospective employees to think carefully about the pros and cons of becoming employed before making a move.

“I’m very upfront with people that this will change their lives and there’s no surefire way to know how it will go,” says Hamilton. “But you can work through a lot of the tough issues and start to form a relationship and build trust in the due diligence process.”

Signing on with an organization that you already know and trust makes the adjustment a bit easier, notes Bailey. Prior to joining Phoenix Children’s, Bailey and his partners had served on committees at the hospital and formed personal relationships with administrators and physician peers.

“We knew what we were joining and that it wasn’t just some big faceless corporation that we had no track record with,” he says. “We knew this was a group that we truly wanted to partner with.”

Employers can ease transition

The same factors that are driving many physicians out of private practice are increasing demand for physicians’ services. As hospitals and health systems form accountable care organizations and implement population health management strategies, they are rapidly adding employed physicians, especially family practitioners and general internists (See sidebar, “An exodus from private practice, on page 46).

Retaining those physicians is just as important, if not more so, as getting them in the door, recruitment experts say. Consequently, many employers are becoming more sensitive to physicians’ concerns and offering programs and benefits aimed at helping them make the transition from private practice.

To prevent physicians from feeling alienated and keep them on board, the larger systems are making significant efforts to give physicians a say in the running of their practice, says Bohannon. 

Phoenix Children’s is one example. It has tried to achieve a balance between integrating new physicians into its system and allowing them to retain some measure of independence, such as developing their own scheduling templates, says Hamilton.

“Our strategy is to maintain as much of an independent practice’s individual brand as we can, particularly in primary care,” he says. “We want them to focus on good quality care while we eliminate some of the headaches.”

It’s also important for employers to keep physicians engaged well past the honeymoon period. After some time on the job, physicians often start to get a little disconnected and employers have to be mindful of engaging them down to the individual provider level, says Hamilton. Physicians have a tendency to want to lead and drive change, or at least participate in discussions, so they can get frustrated if they’re not part of the decision-making.

At Cleveland Clinic’s main campus in Ohio, new hires participate in a week-long orientation process designed to educate them about the history and culture of the system as well as its employee benefits and programs. It also offers a coaching and mentoring program in which new employees are assigned individual peer mentors to help them navigate the workplace.

Moving to an employed situation is a trade-off for many physicians says Bradford Borden, MD, Cleveland Clinic’s associate chief of staff and chair of the Emergency Medicine Institute, who leads the clinic’s recruiting efforts. After years of being their own boss, it’s not always easy to adjust to a team environment.

While acknowledging that physicians will have to relinquish some control as employees, Borden points out that working for a larger organization also opens up opportunities for leadership, education and research that might not be available to physicians in private practice.

Those opportunities present an attractive trade-off for many physicians who see working for a large employer as a way to advance their career, says Cacanindin.  

“Physicians who are business-savvy are drawn by the potential to stand out and perhaps take on a medical directorship that will provide extra income,” he says. “We’re now starting to see physicians who want a seat at the table and organizations are responding to that desire because their voices carry weight with other providers in the organization.”

When hiring, employers look for qualities in physicians that indicate a good fit with the corporate culture, says Bohannon. They want expert clinicians who are also willing to be good corporate citizens, operate effectively in a team environment and pay attention to customer service.

“No organization wants to hire a physician who will have trouble working with others and collaborating,” says Bohannon. “It may seem like a cliché but being a team player can go a long way toward determining whether someone succeeds or fails when they make the transition to employee.”

Ultimately, transitions from private practitioner to employee work out when there’s flexibility on both sides, he says. 

“The more sophisticated employers treat physicians as partners and value their feedback,” says Bohannon. “If you’re coming from an environment with a lot of autonomy, you need to pay attention to that and find out the philosophy of your potential employer in order to set yourself up for success.”