By Dr. Jim Dahle, WCI Founder
I attend the Scientific Assembly of the American College of Emergency Physicians most years. This last year, I spoke three times at the event. In between my own talks, I try to cram in as much CME, learning, and networking as possible. I watched some residents and young faculty presenting their research at one point, and I was fascinated to see a short presentation that included the slide below.
The data applies only to emergency physicians, but I thought it was very interesting. For a long time, I've been telling people that only 8% of emergency docs actually own their jobs. That's not entirely true. That's just the people in democratic groups so small that they only cover a single site. It turned out that my own job, which I very much consider a small and democratic group, now falls into the “regional partnership” category. Apparently, more emergency doctors than I thought are self-employed.
Still, the other statistics are pretty daunting.
How Many Emergency Docs Are Employed by Hospitals or PE?
One-third of emergency doctors are basically just hospital employees, and 25% of them are employed by an entity that is, in the end, owned by private equity. I won't name names, but those of us in the field know who I'm talking about. You can count them all on one hand. I'm not sure what to do with the “national partnerships” or even the “regional partnerships,” though. The bigger the partnership, the more the job is like working for a Contract Management Group (CMG), which extracts something more like 1/3 of what the docs produce rather than a single-digit percentage for overhead like my partnership does. Even at my job, where the partnership is composed of multiple divisions of 10-20 docs controlling the most important aspects of their jobs, there is increasing pressure every year to standardize everything and run the partnership like a big CMG.
After the presentation, I was interested in learning where all this data came from, so I cornered the presenter and learned about Ivy Clinicians, a startup co-founded by emergency physician Leon Adelman. I then hunted down Leon at the conference and learned all about his career path. His path has been very different from mine with regard to ownership of his job. While I have essentially been in a small democratic group ever since leaving the military, it seems like he has encountered just about every terrible job situation possible due to docs not owning their job. Ivy Clinicians is his attempt to do something about it for him, every other emergency doc, and (hopefully) eventually many other specialties. He aimed to replace the “job boards” out there with a more comprehensive solution.
More information here:
How Can I Make My Terrible Doctor Job Less Terrible?: Auntie Marge Explains It All
Avoiding a Boss You Don't Want
Step 1 for Leon was to figure out who owned all of the emergency department jobs in the country. This was a lot harder than it might sound. But eventually the task was completed, and that's where the data on the slide above comes from. I was actually a little skeptical of the quality of the data, so I tried to get some information about my own job. Since I'm on the hiring committee for my division, I figured I'd know the contact person for my group. I didn't, which increased my skepticism. So, I shot off an email, and a couple of days later, I got an email back from someone at the central office in Denver for my now regional partnership who didn't know me from Adam.
OK, maybe the database isn't perfect for a very unique group like mine, but that contact would have gotten me in the right place eventually, I suppose. Although if I were a random emergency doc looking for my job, the contact probably would have at least tried to get me to consider some other places in the partnership that are harder to staff than my division.
Still, I think there is great value being created here. My approach when I went looking for a job upon exiting the military was to call up the EDs in cities with mountains, request the doc on duty, and then ask that doc who did their hiring. I was only interested in small democratic groups (which my group was when I joined) near mountains, so it was a bit of a slow process. Now, young emergency docs can not only shortcut that process, but they can pretty quickly figure out who owns what jobs and, if desired, completely avoid those owned by the hospitals, private equity, and even large partnerships.
Ownership matters. I like owning profitable companies, both my own and others via stock index funds. I like owning my own home and real estate investments. I like owning my job. I think medicine is better—for the docs and for the patients—when docs own their jobs. I recognize not every doc wants ownership, but I still think it should be the standard. Tools like Ivy Clinicians are making that a little bit easier these days.
Most of us complain about the effects of private equity on our workplaces and patient care. Let's start doing something about it. When it becomes harder for PE-associated employers to hire docs, there will be a lot less PE in medical care.
What do you think? Who owns your job? How does that affect your work? Would you like to change it?
Jim I feel like there needs to be another paragraph or two here? How is Ivy helping and what are your thoughts about how this will improve lives of doctors and patients?
It’s not just PE is bad it it? Maybe this answer is obvious to ED docs but I’d like to know more.
What paragraphs are needed to make this post “complete”? Sounds like you want some sort of conclusion or advocacy for some sort of position. What should that position be? I just thought it was really interesting information worth sharing. And I don’t want every post I ever write to be 3000 words.
Yes if like to know your opinion. I read the blog partly to hear your take as an opinion and thought leader. The post is interesting which made me want to hear more about your thoughts on this and where it may be going… perhaps in a future post.
I also was interested in hearing more about Ivy. I clicked on the link and the section that says Why Ivy left me also looking for a stronger understanding of what they do and why. I felt like there may be some unspoken subtext that I don’t know about as a non ED doc.
This isn’t a complaint. It just left me wanting to know more.
If you want a specific opinion you have to ask a specific question. I’m not really sure what yours is.
As noted in the post, as a general rule I’m a big fan of doctors owning their jobs. Lots of variation, but most of the time I think that allows doctors to make more, control their work environment more, have less burnout, and do better patient care.
Personally, I’m basically unemployable at this point in my career. No employer would offer me a job I’d be willing to take. If they don’t need me 9 months a year (my “vacation requirement”), they don’t need me at all.
What exactly is the problem Ivy is trying to address and how are they addressing it?
Is it simply that docs are unaware that they’re working for a non doctor friendly employer?
Do you think that Ivy’s model will fix the problem?
Oh, you want an opinion on Ivy as a company. Well, it’s a new company so things can change and I’m sure there are some business practices I will like and some I will not. They are not an advertiser here at WCI so I have no conflict of interest. But I think the business behind it is basically a job board. Since it can cost $50K to recruit a doc, there’s a lot of money possible in facilitating physician recruitment and they’re trying to get their slice of it.
The problem is that doctors take crappy jobs so crappy jobs keep existing. Hopefully showing doctors that they don’t have to take crappy jobs will encourage them not to do it anymore. Empowering docs with information is behind the missions of both WCI and Ivy. Here’s their FAQ page: https://www.ivyclinicians.io/faq/all
If I thought they were a terrible company I wouldn’t mention them or link to them. But I don’t have enough info nor am I being paid to make any sort of endorsement. If you want an EM job, might as well use what’s there, no?
That helps a lot. Thank you. I think we have more transparency in dentistry so I wasn’t aware that it may be harder to determine the quality of the position in EM.
Jim – which 3 months are you willing to work, and which 9 months are you wanting NOT to work? 🙂 might be worth a discussion….
Not worth a discussion, sorry. I’m willing to work 6 days a month pretty much all months. Maybe 8 in Nov-Jan if I could do fewer than 6 May-Sep, but it’s just 3 months total. If I were interviewing for a job I’d be asking for 3 weeks off every month I suppose, not 9 months off each year.
I have never known who “owned my job” but I’ve been an employee since I got out of residency in 1994. Generally, it seems to have been the hospitals or clinics where I worked.
A few times I calculated the financial difference between being an employee and being employed after dozens of people mentioned “you should have your own practice.”
It always seemed better to be an employee with a comprehensive benefit package and 5-6 weeks of paid vacation than to be the boss of my own business. When you own a business, it owns you to some degree and taking time off “without pay” seems like it would affect the enjoyment of being off. I suppose in some specialities this is a lucrative career choice filled with autonomy and freedom?
Of course, it helped that I was the medical director at most of the places I worked. It’s good to be the “boss” even if you don’t own the business. When I was not the director at two positions that lasted only about one year each, I left and went looking for another medical director position. In both cases I was asked to see too many patients and discussed it with “the boss” but it had no effect.
It’s funny to me that in order to support the “employee physician” side of the coin, I have to admit it was not very good unless I had a lot of autonomy, a reasonable patient load, and a responsive boss…or I was the boss. When I was asked to do an unreasonable amount of work, I left. That was easy in psychiatry as there were so many jobs…if I was willing to drive 40-50 minutes.
After a fashion, I’m my own boss (set my own hours/schedule) but am also employed by a small group owned by PE. PE takes a portion of overhead with the hopeful agenda of cutting purchasing costs and negotiating higher reimbursement from payors. I still eat a portion of what I kill, but the overhead is higher at baseline. Even still, I out-earn most of my colleagues in my same field because I’m willing to grind more. This arrangement works out when you want to hustle, but it does cast a shadow on vacations. Once I reach FI, I can be more flexible with my schedule with less impetus on volume and hopefully have a bit of the best of both worlds.
Nice article as always, Jim. Is there any data on physicians that were previously owners who then became employed and if they are actually doing better financially? I know from my experience I was a partner in a practice for two years and I made significantly less income given our overhead expenses versus when I became employed. Unfortunately, we frequently ran into the dilemma where sometimes the best business decision is not always the best doctor/human being decision. For example, one of the other associates who was on a partnership track in our practice her husband needed a kidney transplant and we allowed her to takeoff for six months while she cared for her sick husband. That was the best human decision to do but not exactly the best business decision by far for our practice. Examples like this where I’m suspect whether being an owner is actually that lucrative because in order to be a successful business owner, there does have to be some compromise between being a nice person versus turning a profit.
I know that you have data in the ER space where owners make more than employed docs, but I wonder if there’s some survivorship bias just like in mutual funds. For myself, I know my low income as a partner is no longer reflected in the neurology space and so the owners that are doing well will survive and jack up the average income of owners and make the neurology owners look better.
Yea, there are LOTS of times now when docs make more by becoming employees. They’re not doing it because they’re stupid. Health care economic forces are making it so owning your own business often means making less, so docs sell their practices to PE or hospital systems or just walk away/close them. Plus there is definitely some hassle owning/running a business. Like the example of your partner, our partnership does stuff that might not make “business sense”, at least in the short run, but in the long run reduces burnout and boosts happiness and career longevity. Imagine being in a partnership where no one leaves because they know they will be treated worse elsewhere. Where everyone is in their last job. Doctors can create those partnerships. What’s good for doctor career longevity is also good for patient care.
well said. Luckily it seems like your group is able to survive those “short run does not make business sense” dings. Ours didn’t 🙁
FP- Army and then civilian Army, VA, FQHC except when I was locuming UK and US. Aside from relocating a lot (Army spouse) I figured I am not the best manager (did 3 years as Clinic Cmdr in the Army, 2 clinics, and prefer just doing medicine) and might spend more hours working were I the manager/ owner than as an employee. Also saw in the Army that in FP pay inside was not too bad compared to pay outside, unlike the specialties that leave the military ASAP, and control and power increases over time (though never free of deployment/ war risk of course- but more patriotic and acceptable to those who stay than company owner changing the rules and suddenly your job really sucks and you really need to quit). Would likely have stayed active duty were we childfree or my spouse not Army 20+ year and kids likely to be raised a few years by grandparents were we both lifers.
Doctors take bad jobs with bad employers because they prioritize 1) location and 2) pay. Also, your clinic team MA, nurse, practice manager have a lot to do with how happy you are at the end of the day.
Putting the responsibility on new grads or job changers to steer clear of these jobs is abdicating the responsibility we all have. For example, plenty of doctors are still moving to Asheville NC even though HCA has made a mess of healthcare in Western NC.
ALL of us need to know the names of our board of trustees of our hospital. And if you work for private equity, you need to know the board of directors. You don’t have to join a committee or go to meetings to send an email every now and then reminding these people that patients, doctors, nurses and staff are the mission not just the margin.