This story is part of a series examining how trends in healthcare ownership are impacting physician practice. Click here for the main story on employment trends, and here for a sidebar on how private equity in particular is driving employment trends.
When Rebecca Berens, MD, was just 4 years out of residency, she was already experiencing burnout.
Berens, a family medicine practitioner based in Texas, spent her early career working for a federally qualified health center (FQHC) and subsequently, a county health department. The work aligned with her mission of wanting to treat underserved populations. But working for the large systems took a toll.
At the FQHC, Berens, 32, was required to see 21 patients a day or more. Her appointments were booked one after another, and she saw a patient once every 10 minutes.
"When you're seeing so many people back to back, you start to feel like you're just a robot," Berens told 番茄社区. "You're just refilling meds and ordering tests, and there's not really the time or space to think about a case."
If a patient needed more time, Berens often didn't have the authority to give it. She couldn't double book a patient without getting approval from administrators, and she often had to make several requests just to exercise her best clinical judgment.
"I felt like I was constantly fighting so many little battles day by day, just to get basic things done," Berens said.
When Berens had her first child, she knew something had to change. She still held tight to her workplace values, but didn't want to endure the long hours, bureaucratic hurdles, or additional stresses now that she had a baby at home. So, she opened her own direct primary care practice.
"I think it was just a reevaluation of my priorities," Berens said. "I thought, how do I want my career to work?"
As the number of physicians employed by large health systems is steadily increasing, doctors like Berens are searching for ways to maintain autonomy over the way they practice medicine in an increasingly consolidated healthcare landscape.
For some, autonomy means divorcing themselves from the conventional healthcare system, and wading into alternative healthcare delivery models like direct primary care. But others have found ways to maintain ownership over their work -- and life -- by operating within the system.
The World of Direct Care
Berens opened her direct primary care practice in January of 2020. She charges patients a flat, monthly membership fee of $99 per patient or $150 for a family of two (adding $50 for each additional family member), without any co-pays, co-insurance, or deductibles. That monthly rate includes office visits, virtual visits, physician text services, and some procedures. Patients pay separately for medications, lab work, x-rays, and other tests, but she can offer some of these at lower rates.
Now, instead of seeing more than 20 patients a day, Berens sees two or three in person, and texts or calls an additional five to 10 (though she still plans to grow the practice). Rather than squeezing a visit into a 10-minute time slot, she can offer patients up to an hour and a half.
"I'm able to do a lot more healthcare system navigation," Berens said. In addition to spending more time with patients during their visits, she has time to research price-transparent specialists to refer them to, or even read up on conditions that she can treat herself. Since Berens has more time to research and do a greater proportion of the workup in-house, she refers patients out less often.
Berens also said she has more autonomy over her scope of practice. Procedures such as IUD insertions, skin biopsies, or joint injections -- which were not possible for her to do when she was working for the larger systems -- have become frequent in her practice.
"I don't have anyone else telling me what procedures I can and can't do," Berens said.
The movement to direct primary care has gained popularity in recent years -- particularly among doctors who feel disillusioned with the current system. There are currently around in the U.S., which serve more than 300,000 patients, according to the Direct Primary Care Coalition.
Berens still treats an underserved population. The majority (70%) of her patients are uninsured, and many are self-employed people looking for affordable healthcare. The freedom to spend more time on patient care, as well as have her own schedule, has improved her job satisfaction.
"Autonomy was a huge part of why I decided to go into direct primary care," she said.
Maintaining Control in Private Practice
Not all physicians feel the need to abandon conventional practice models to stay independent. Carolynn Francavilla Brown, MD, a family medicine physician who owns her own practice in Colorado, said being self-employed was imperative to her ability to practice medicine.
"Autonomy really was the reason why I decided that having my own practice was essential," Francavilla Brown, who also serves on the American Medical Association's (AMA) private practice governing council, said in an interview. "I felt like I could best treat patients by doing things my own way."
Francavilla Brown, 37, was board-certified in obesity medicine after she finished her residency. She began to interview at some of the large corporations in her area, but said that none understood the value of obesity medicine in primary care. Francavilla Brown wanted the flexibility and control to give her patients the care she thought they deserved.
"I didn't believe I would ever be able to really improve patients' lives with 15 minute appointments," she said. "I wanted to focus on individuals on my own, as opposed to sort of the metric-driven healthcare that doesn't really take into account the individual patient sitting in front of us."
But spending more time with patients -- and maintaining the autonomy in clinical practice -- meant thinking strategically about her business model. Francavilla Brown said the key to keeping her practice afloat has been both cutting costs and being flexible about her desired income.
Francavilla Brown cuts rent costs by occupying a small office space, which she has kept minimal by optimizing her practice's telehealth use. Additionally, a major place to keep costs low is in support staff.
"We have a much leaner staff," Francavilla Brown said. Physicians at her practice often take vitals themselves, and are in charge of calling back their patients to follow up on appointments.
Francavilla Brown's practice also employs premed students. She has hired students who are thinking about medical school, or other careers in healthcare, to help with administrative work -- and who will often work at a lower wage than someone with more experience.
Francavilla Brown said providing experience to premed students, which can be difficult to get before medical school, is a way to give back to aspiring providers. "At the same time, it has been a really nice staffing solution," she said.
Autonomy in Corporate Medicine
While many doctors have opted to run their own practices to stay independent, some believe that working for larger systems actually offers sufficient autonomy.
Nancy Fan, MD, an ob/gyn at St. Francis Hospital in Wilmington, Delaware, who also serves on the AMA's organized medical staff group, made the switch to working for a health system after more than a decade owning her own practice. Her current hospital is a part of Trinity Health, a non-profit system that owns more than 90 hospitals in the U.S.
Fan, 53, said she believes she has a lot of autonomy as an employed provider, acknowledging that she may have more freedom than the average employed physician. While some clinical protocols come from the top down, those are typically best practices that she would abide by anyway.
There are administrative protocols, too, but those are decisions she would rather defer to someone else.
"A lot of people last 5 to 10 years [and] are ... completely burned out by the administrative burden that comes along with running your own practice," Fan said. "Medicine does not prepare you for that."
Prior to starting her employed position, Fan and a co-owner ran an independent practice for 12 years, employing about 10 to 15 staff. That began to take a toll when Fan and her partner had to make tough business decisions that she didn't want to make, such as whether they should provide their employees with a higher deductible health plan to cut costs, or whether they could afford to offer disability benefits.
"I was starting to have to make choices that all business owners have to make," Fan said. "But that weighs on your mind quite a bit, recognizing that you're providing the salary for 10 to 15 people. This is their livelihood."
In addition to the administrative burdens, Fan said that running her own practice was a financial challenge. Ob/gyn is a labor-intensive speciality, she said, due to the need for additional staff to supervise all procedures. Staffing became a major cost that she could not scale back on.
Fan and her partner had to work at the top of their outputs to not only make their desired income, but also provide benefits to their staff. Both had small children at home, and work became a burden on their families.
"It was fine to do logistically, for a little bit of time," Fan said. "But year after year, I was like, 'You know what, I don't want to spend my whole life doing this.'"
So when Fan switched to her employed position, she gave up her freedom to choose her staff, or do things entirely based on her own judgment. But she also said there's a tradeoff -- and sometimes, giving up some freedom actually provides more autonomy.
"If you're talking about autonomy, it's really about control," Fan said. The amount of authority to surrender is a decision that all physicians have to make, she said, but when it comes to the administrative component, the tradeoff for her was easy: "I have no problem giving up that control."