If you want a useful analogy for what’s happened to physicians over the past few decades, skip guilds, skip unions, and skip “burnout culture.”
Look instead at the company town.
In the late 19th and early 20th centuries, company towns were common in mining, railroads, and manufacturing. Employers didn’t just provide jobs. They owned the housing, the stores, sometimes the schools, and occasionally the police.
Workers were often paid in scrip (that is, coupons or fake money), usable only within the company town: They paid you in fake money to work and then you paid them back in fake money back to live. If you were able to save for your fake future, it was in fake money.
No one needed to be coerced. The arrangement solved real problems. Housing was scarce. Work was unstable. Infrastructure didn’t exist. The company town offered predictability and convenience.
And for a time, it worked. But then it didn’t.
The problem was structural. When a single institution controlled employment, income, housing, food, and social standing, independence became nearly impossible. Leaving meant losing everything at once. Negotiation was theoretical. Loyalty became compulsory. Heck, it was the covenant not to compete on steroids.
Hospitals today are not coal companies. But the parallels are hard to miss.
Hospitals increasingly control not just where physicians work, but how they are paid, how referrals flow, what technology is used, what data is accessible, and what constitutes “acceptable” practice. Employment is marketed as support, as “relief” from billing, regulation, staffing, and capital constraints, just as company towns once were.
Most physicians didn’t “sell out.” They made rational decisions in an increasingly irrational environment.
But when one institution controls your income, your schedule, your referrals, your infrastructure, your data, and your professional legitimacy, the relationship changes. Credentialing becomes leverage. Scheduling becomes authority. Metrics become judgment. Exit becomes expensive long before it becomes impossible.
Company towns didn’t end because they collapsed overnight. They ended because alternatives emerged. Public infrastructure. Labor mobility. Independent housing. Once those existed, the monopoly no longer made sense.
Hospitals will remain essential in one form or another. That’s not the question.
The question is whether hospitals need to function as company towns for physicians.
History suggests they don’t. And when alternatives become viable, as they are now, dependence stops looking like safety and starts looking like inertia.
As difficult as it might appear, there are multiple ways out.
Let’s talk when you’re ready to break free.
