Dr. Roman Rumpelstiltskin (real person, fake name) walked out, no, to be truthful, was thrown out, of Big Hospital Medical Group just before noon.
Less than three weeks later, he and a suitemate were ensconced in their own office a bit more than a half mile away.
Today, a few years later, his income has boomed, his vacation time has increased, and he’s no longer answering to an asshole administrator.
You might not be a Rumpelstiltskin. As they say on TV commercials, “professional driver, closed course.” But maybe you are.
Over the past several weeks, I’ve seen multiple posts and comments on LinkedIn about the horrors of practicing as a cog in the wheel of Big Medicine, employment schemes facetiously referred to as “medical groups” by their health system or insurance company owners. The complaints can roughly be sorted into those involving control of workload, control of compensation, and control of patient care.
Undoubtedly, the complaints are valid. However, some proffered solutions tend to be worse.
Many of the physicians doing the posting think that it’s time to unionize, even to call in the Teamsters or the Service Employees International Union to stand behind them, I suppose on an actual picket line.
Although unions have been successful in obtaining wage increases and, going back a century, better working conditions, for laborers, ask yourself if any union has ever, in the entire history of organized labor, turned laborers into owners with actual control over their destiny? Nope; they’ve turned the workers of the world into better paid and better treated and less likely to be crushed by heavy machinery workers of the world.
Then why would anyone think that any union could do anything other than turn physician union members into anything other than better paid workers? Why would anyone think that a union would wield a blow against factory-like patient care, against being told how to practice medicine, against being told to whom to refer, and the like?
What’s the real beef?
Is it money and working conditions, about which a union might help the proponents, or is it more than that? For those like Dr. Rumpelstiltskin, it was more.
Are the patient care and corporate practice of medicine issues real for the union proponents, or just dresses on a pig? It appears that for some or even many of the folks on LinkedIn, it’s size 6.
So, how did we get here?
I posit that it’s the result of what started with a bolus of truth—“you didn’t go to medical school to run a business, so let us do it while you practice medicine.” But over the ensuing years which became decades, the businesses disguised as hospitals and “physician practice management companies” grew to control the practice of medicine, not just perform the administrative tasks.
At the same time, statutes and regulations that were supposedly created to control the evils of financial inducements and self-referral became cudgels that swung in one direction only. Prohibitions supposedly adopted to stamp out the referral and utilization concerns claimed to exist when doctors own hospitals, magically disappeared when doctors are owned by hospitals, in which case referral and utilization concerns are alchemized into “seamless integration of care” or some such bullshit.
So, where to go from here?
Do the physicians advocating for unionization understand that the mere act of unionizing is a confirmation of the fact that business is actually in charge of medical practice? Just like the cashiers at a supermarket chain, the union is interposed between the workers (physicians) and the those owning and controlling the enterprise (the hospital, some physician practice management company, five MBAs in Manhattan). The owners are still the owners. However, the union is now empowered—“you didn’t go to medical school to deal directly with your employer, so let us stand in between you and your employer”.
Do the physicians advocating for unionization understand that unionizing will further commoditize them in the mind of the public (this physician or that physician, physician as “provider” and physician assistant as “provider”, etc.) and in their own minds?
Have they, or you, whether or not you’re advocating for unionization, considered that continuing to play the game with the business’s ball on the business’s court with the business’s rules will get you the same result, perhaps with a few more dollars in your pocket?
Or, do you return to asking basic questions about the practice of medicine and its bounds and consider what other structures might work better for you and for your patients? Can practice actually be separated from administering the practice? If so, at what segment? What guardrails exist to enforce the segmentation? What do patients expect and how best to deliver it? Is integration of financial matters actually required to coordinate care? Those are but a few examples.
That’s what physicians like the one I’ve disguised as “Dr. Roman Rumpelstiltskin” did. That’s what various cohorts of hospital-based physicians I’ve helped to form their own groups did. That’s what the internal medicine doctors escaping the car crash that followed the sale of their former practice to a hospital did in reestablishing their new practice.
But the unionization crowd claims that that’s “hard”. And they’re right. But is “hard” really the point? What’s worth fighting for?
It’s fine if you want to outsource everything. But that’s what led to physicians becoming corporate employees. Just don’t complain that it’s gutted your profession, or think that a new daddy, some union, will kiss the boo-boo and make it all right.
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