The practice of medicine is more complex than at any time in history, and many physicians are finding themselves at a crossroads: Should they continue to pursue independent practice, or should they accept an offer for employment? Some of the physicians wrestling with this decision are long-time physicians who hoped to ride their current practice into retirement but now feel forced to take a different path at the end of their career. Others are new physicians who, as students, dreamed of graduating from medical school and residency, hanging out a shingle, and practicing independent family medicine; however, they now find themselves facing a much different reality. Still other physicians remain committed to private practice despite the challenging times. According to a recent survey, among 2,094 physicians who own their practices, 58 percent said they are not looking to sell.1
Regardless of where you are in your career, it can be helpful to examine your emotions related to independence versus employment and reflect on what such a move might mean. There are numerous articles available to help you assess the business aspects of leaving private practice (see the resources below). This article addresses the often-overlooked psychological issues.
Denial vs. awareness. When faced with difficult issues, our default response is often denial. Are you denying that you need to make a decision about your practice? Just as some stay in a personal relationship long after it is viable, have you stayed in your private practice too long? Some say that small, private medical practices will largely be relics of a past era before long. Others say the current practice sale frenzy is simply history repeating itself. What is the reality in your community? Are you looking honestly at your situation?
While denial can be a healthy defense mechanism, it becomes destructive if we use it for too long or ignore vital issues. Awareness puts you in a more advantageous position. Making an informed decision while you have time to process it, absorb it, and adjust to it gradually is much better than waiting for a crisis moment and rushing a decision. I have witnessed great physicians increase their clinical work while they ignore or deny other important aspects of their lives or practices because the clinical arena is where they are most comfortable. However, problems and issues do not always get solved this way; taking time to gather information and reflect can bring clearer and better solutions.
Trust vs. suspicion. What is your level of trust or distrust toward your potential employer? Developing trust takes time. As a long-time marital therapist, I have known a few couples who met on a Friday, were married the next day, and ended up with a decent marriage, but that is not the rule. A longer courtship has value, even when the suitor is a hospital or health system. Many new relationships between physicians and hospitals or health systems do not work out. Just like in marriage, both sides bring baggage and their own unique perspectives and expectations. If you don't understand this, the initial enthusiasm can deflate rather quickly. A relationship with a new employer should not be based solely on emotions, feelings, or superficial attractions. Instead, both sides need to communicate, clarify, and seek to build a solid, trusting relationship.
Steadiness vs. reactivity. Are you considering this career change while experiencing burnout, betrayal by a business partner, fear, or from some other reactive position, such as a financial shortfall? Make sure you are not running from something. Rushing from a crisis into a new relationship rarely ends well. In the midst of stress, we often long for something to give us energy or to take away the emotional pain, making us susceptible to looking for a false savior or rescuer. Needy or desperate people do not always make the best choices in their relationships and partnerships. That being said, change can bring renewed energy if you enter into the relationship wisely. The relationship needs to be a mutually beneficial commitment based on a joining of strengths, not just a temporary fix or a temporary high, similar to what a marital affair might provide.
Who you are vs. who you will be. What impact do you think becoming an employed physician would have on your identity? Most likely, you have invested your heart and soul in your practice. It is yours; it is part of you. Can you merge with a hospital and still feel good about who you are? Do you fear becoming a cog in the hospital machine, or is this an organization you will be proud to call home? Might being connected with others or under the umbrella of an institution provide a greater sense of identity? Clear boundaries regarding what is expected in the relationship by both the physician and the employer can assist in defining how your identity might change.
Independence vs. partnership. What impact would the change have on your autonomy? There is something powerful about hanging out a sign with your name on it and knowing the practice is yours as you walk in the door each morning. For the most part, you get the final say in what takes place. How much autonomy will you be able to maintain as an employee? Some struggle with the loss of control. Depending on your contract, the loss of control can be limited or rather extensive, but make no mistake: You will have less control. If you do not resolve this well, the relationship may quickly be in jeopardy.
Career vs. change. What impact would a move to employed practice have on your career? Your vision of your career may have to change. This is a reality of most career journeys today. The ability to stay at one job for 30 years is gone for the most part. Those who survive and thrive into the future will need heavy doses of flexibility and adaptation. What dreams about your career are you giving up, and what dreams might you be gaining?
Selling out vs. joining up. What are you feeling about selling your practice and joining a larger organization? If you view it as selling out, caving in, or giving up, but later decide you must sell, this may cause cognitive dissonance. This is a time for what therapists call a “reframe”: You must put a new frame or structure around the issue. Find a more positive and less cynical way of thinking that emphasizes the good in joining up with a hospital or health system (e.g., relief from certain administrative or business responsibilities). If you fail to do this, you risk getting caught up in chronic cynicism and disillusionment, and you will crash and burn, both in your spirit and as an employee.
Eyes wide open vs. blind spots. An old adage attributed to Benjamin Franklin may apply here: “Keep your eyes wide open before marriage, and half shut afterwards.” Of course, you need to keep your eyes wide open even after the fact, but it is particularly important as you enter into a new relationship. The questions listed throughout this article are designed to help you be aware of potential blind spots. In addition, talk to trusted persons who can point out issues you simply cannot see by yourself. Make sure you've considered the costs and benefits – financial, emotional, relational, and otherwise. Even after you have entered into an employment agreement, keep your eyes open to any signs that you may need to make another change down the road or perhaps get support or counseling to help you adjust to your new role.
QUESTIONS FOR SELF-REFLECTION
Take a few moments to jot down your answers to the following questions. Committing your thoughts to paper can help clarify them.
Denial vs. awareness
What is the reality in my community? What signs are there that I need to leave independent practice now or in the near future? What other options might I have?
Trust vs. suspicion
What is my level of trust toward my potential employer? What qualities have I seen in the organization or its leaders that suggest trust is likely?
Steadiness vs. reactivity
Why am I considering this move? Is it for strategic reasons, or could it be a reaction to burnout, betrayal by a business partner, fear, or some other issue?
Who I am vs. who I will be
What impact would this have on my identity as a physician?
Independence vs. partnership
How much autonomy would I be able to maintain as an employee, and how do I feel about this loss of control?
Career vs. change
What impact would this have on my career? What dreams would I be giving up, and what dreams might this make possible?
Selling out vs. joining up
Do I view selling my practice as simply “selling out,” or are there positive aspects to joining an organization?
Eyes wide open vs. blind spots
Have I talked to someone I trust about this, and have I considered the costs and benefits – emotional, relational, and others?
Now is the time to reflect
Career transitions are critical, often difficult, points in life, and you can easily get stuck at these times. Far too often, emotional and psychological issues get neglected or ignored but come to have a profound impact later. The key point of this article is to take time to contemplate these issues when considering employment with a hospital or health system. (Use the self-reflection form to commit your thoughts to paper and help clarify them.) Otherwise, you may find that although “marriages are made in heaven,” business relationships can heat up quickly and remind you of another less blissful place. Moving carefully and thoughtfully with all aspects of the transition, including the psychological, can help you arrive at the best decision for your life and your career.
The following articles from the FPM archives may help with the business aspects of transitioning from independent to employed practice.
Borg S. ACOs are coming: should you sell your practice? Fam Pract Manag. 2012;19(2):15-18.
Burke MR. Evaluating employment agreements. Fam Pract Manag. 2012;19(4):6-10.
Izor DG. “Why did your productivity decrease when we hired you?” Fam Pract Manag. 2011;18(4):18-21.
Kalogredis VJ. Nine practice sale pitfalls to avoid. Fam Pract Manag. 2012;19(3):22-25.
Rothenberger R. Selling your practice doesn't have to mean selling out. Fam Pract Manag. 1998;5(2):24-30.