Along with many physicians of the millennial generation, I have discovered that the only power I can really exert in this dysfunctional health care-industrial complex is in my willingness to walk away from job conditions that I cannot countenance. I was ready to quit medicine during my first residency (in spite of my loans) not because I wasn’t still enamored with pathophysiology but because I had an inkling that the system wasn’t really built around empathy or high quality patient care since neither are possible under extremes of sleep deprivation. In retrospect, perhaps I should have. Instead, I changed specialties.
During my second (PGY4) year, my anesthesia residency program failed to fill in the Match and we senior residents worked just that much later as the evening shift clean-up crew. Instead of expanding the workforce — with CRNAs, or more attendings — to provide protected academic time (not to mention adequate sleep), our program opted for the cheaper option of just paying the residents a marginal sum for hours worked in the late evening, regardless of willingness.
In my first practice, I left because my group was billing fraudulently while allowing CRNAs to practice essentially without supervision. Fearful of an inevitable lawsuit, I reported a series of poor outcomes to the hospital administration in the hopes that the system would be altered to better protect our patients. Instead, I was maligned by the entire department, physicians and CRNAs, for “betraying the departmental trust.”
In my second job, I started with a reasonable contract, but left anticipating the fallout when my physician-led, nonprofit, critical-access health system sold out to a for-profit entity for quantities of money I could barely fathom. The signs were clear when all of the upper level physician administrators were summarily dismissed and our collegial, transparent department was split into subspecialty groups for new contract negotiations, breeding suspicion and distrust.
Make no mistake, business is about gamesmanship, relationships, negotiations, and strategy, and the business of medicine is no different. To believe otherwise is almost negligently naive. And even in writing of this essay, the themes become more glaringly obvious: understaffed and overworked is dangerous for both patients and physicians, but who cares? The profit margins are better.
My current private practice was born as the brainchild of physicians of the baby boomer era and early generation X. The goal was simple: to build an extremely profitable model, and sell it for as much as possible. Relative to the risk profile of most business startups, this practice was the equivalent of a “sure thing” in that the payer mix was the stuff of legend — affiliated with an elite, internationally known boutique orthopedic surgery group, the percentage of Medicare billed was under 5% and there was a significant proportion of up-front cash pay patients.
Fast forward eight years, one global pandemic, and almost a decade further into the corporatization of medicine. Private equity has entered the game of owning physician(s and their) practices — a sure sign of too much blood money drawing the biggest sharks. Jaws, as it turned out, swallowed the elite orthopaedic surgery group whole just prior to my arrival.
I was hired as an employed physician with no possibility for partnership (another profit-maximization strategy of the founders). Still early in my career, that prospect didn’t particularly bother me. I thought that I was doing the right thing for my family, combatting impending burnout by moving to a small community with very healthy patients to do easy orthopaedic cases as a way to lessen my stress and improve my work-life balance. For the first two years, I worked less than I ever had before for my highest-ever salary: 35 hours a week in summer, 55 hours in winter (when ortho-trauma volumes increase our overall caseload by 35%). But I was miserable, because I had not anticipated the social dynamic of not being a partner. My lesser status in the business translated directly into lesser clinical status, deliberately kept out of the rooms of the top surgeons, underutilized and undervalued. My regional skills eventually got me promoted into those rooms, though without the monetary bonus given to partners for the same work. So I interviewed elsewhere, loath to uproot my family again, but at a loss for what else to do.
Then in my third year, the group decided to offer me a partnership, along with the two other excellent physicians who joined when I did. Finally, my luck was changing! Little did I know how fractious the group had become as its financial largesse had dwindled. Within three months of becoming a partner and with an inflated sense of my own agency, I ran for and won the position of group president. Based at least partially on my vision for the future, one replete with work-life balance, mutual support, and a culture of intrinsically valuing people as people with lives and families and talents and setbacks, we decided that every future hire would be partnership-eligible within one year and created flexible part-time and hardship policies. On that foundation, we recruited six talented, mid-career physicians, secured an army of locums, and weathered the existential threat of a service disruption in our busy winter season.
I have been the chief of my group for 18 months. Financially, 2023 was a banner year, though the credit is not mine; the partnership as a whole worked 1.2-1.5 FTEs each for those lofty salaries. I have had a crash course in the business of medicine, since the medical education system flippantly dismisses the fact that doctors do in fact need to earn a living in order to ensure longevity in the field. Meanwhile, the fundamentals that drove away the more fiscally-minded partners have not changed. Between Medicare creep (now 33%), decreased block reimbursement, widespread adoption of international health insurance, and rate cuts across private insurance payers, our average unit value has been cut in half over the less-than-a-decade life of the practice. Coupled with workforce shortages and expanded service demands driving 5%-10% rise in salaries and a mind-blowing 72% uptick in locum rates, our group faces either legal liability from a contractual breach for service disruption or financial insolvency going into another winter season. Five pending resignations sit on my proverbial desk.
As I suspect it may be for many physicians, I find problem-solving seductive. I appreciate the insight that comes with second-guessing my own motivations, values, and philosophical leanings, and attempting to understand how those things line up for others in ways that may be different from mine. But how I spend my time, and how much of myself I give, has serious consequences when the allure of problem-solving causes me to neglect the other things that I also highly value: reinforcing my marital relationship, parenting my children, and my own health and well-being. That is only even more true when the problems that I’m trying to solve are symptoms of deeper systemic issues over which I am relatively powerless and in the face of which my analytical skills and enthusiasm are effectively useless.
Physicians are still the face of medicine, but in reality we represent the perfect scapegoat in between people who want the benefit of our care and expertise, and to whom we desire to give it, and a series of ever more distant overlords who win by complicating, delaying, and denying that relationship while purporting to do no such thing. Meanwhile, our shared personality traits have been manipulated, often deliberately, to benefit only the system and its metrics of production, transforming us into widgets: identical, easily replaceable, and literally worth-less (and less and less).
My brother, who is also a physician, shared with me a key piece of advice from one of his attendings in training that resonates powerfully: the hospital will never love you back. Except it’s not just the hospital — the system will never love you back, unless you are the perfect, most compliant and productive widget and only as long as you stay that way. And even then your patients will blame you as the most proximal and convenient target for the failings of the system.
When we complain about how it feels to try to care for others in an industry that cares so little for us, we are further degraded by de-valuing labels: lazy, ungrateful, entitled. Monetary compensation is a poor surrogate for meaning and purpose, and soothes that cognitive dissonance for only so long — usually long enough so the mantra becomes physicians on FIRE (financial independence, retire early) such that despite increases in compensation, our workforce shortages continue to climb and long-term retention is no better regardless of earning potential.
I had dinner recently with three anesthesiologists who have found a workaround that, for now, still allows practicing medicine to work for them: full-time locums work. They all feel like now they get to provide high-quality patient care, bolstered by control over work schedules such that they have enough time for relationships, adequate sleep, and recreation. I have discussed this option with my own family, and was dismayed to have my two oldest children, 9 and 11, beg me to take a job that takes me away from them for possibly weeks at a time in exchange for being predictably, wholly with them when I am home.
I have not yet resigned. I am still hopeful that I can maneuver a “soft landing” for my group as we either transition or fail or both. I am hopeful that I do not have to move my family yet again. I am hopeful that if it comes to that we can negotiate a fair employment contract that keeps care available to the patients in my community. So though I have not yet resigned, I am resigned: to the possibility that working locums, and becoming a part-time absentee in my own life, is the best of all of my bad near-future options.
For me personally, having been in different models of practices under different umbrellas of health systems, no amount of money has given me what I really want: the ability to practice a job that bizarrely I really do still love with time and attention left over to spend as a wife and a mother and a friend — the ability to practice my art while still being a whole person who has intrinsic value. If I could find that, I’d consider working forever. But our system is broken, and any attempt to call attention draws the ire of the vested interests and a campaign of character assassination that is deeply disturbing. So if and when I do exit the profession, it will be with no small amount of regret, but with the one thing that I had to teach myself in spite of my job — self-compassion.
Shannon Meron is a private practice anesthesiologist in Vail, CO.
Illustration by April Brust
