Just as interestingly, a similar trend is occurring in academics. Thinking back 15 years to when I was a medical student, the academic urologists I knew were all “triple-threats”: phenomenal surgeons, renowned researchers, and stellar teachers of residents and medical students.
On the other hand, it seemed that every patient they dealt with was super complicated and most cases required big-time surgery. None of the academics I knew did bread-and-butter urology. The simple cases were left to the private practice urologists, and it was simply expected that the bigger cases would be referred to the academic centers.
So what changed? In a word, reimbursement. As state and federal funding for academic centers declined, hospitals had to think of ways to raise revenue, and a few clever centers decided to start directly employing urologists to do private practice urology. The best example I can think of, though I’m certain there are others, is Cleveland Clinic. We all know that Cleveland Clinic has world-class research and provides true cutting-edge surgery. What I didn’t know until a few years ago is that it started establishing Cleveland Clinic-branded outreach clinics throughout northern Ohio that are staffed with Cleveland Clinic-employed physicians.
The advantage of this model is that not only does the Clinic have more control over referrals, but it also reaps the financial advantage of owning the private practice urologist. The model was so successful that nowadays, just about every major academic institution uses this model to some degree. In my backyard, the University of Colorado in Denver is actively buying up practices along the front range to increase its footprint. My group is no exception, as we were also approached (we declined).
Why does this matter? As you may know, I am a strong believer that physicians provide better patient care when they are involved in the business side of medicine. I realize some people disagree with that statement, and I understand their argument. There are certainly doctors who, because of their laser focus on the bottom line, allow money to dictate their care to the detriment of the patient. On the other hand, neither physicians, nor our patients, nor the health care system as a whole has unlimited resources, and understanding the costs of the treatments we provide, while working to minimize those costs where appropriate, makes the system stronger overall.
It is for that reason that I question the trend toward hospital-employed physicians, whether those physicians are employed by for-profit hospitals or academic centers. To be clear, I am not referring to those physicians who continue to practice what I consider to be “traditional” academic medicine. These physician-scientists need the freedom to explore their passion and to provide the incredibly complicated care they do without thinking about costs, and that likely means that we, as a society, need to find a way to fund them appropriately. Rather, I am referring to the employed physician who gets up in the morning, goes into the trenches of urology, and provides the same small-town, guideline-based medicine that I do.