The changes that have occurred in health care over the past 30 years have been dizzying. From the movement toward managed care in the 1990s to the publication of the joint principles of the patient-centered medical home in 2007 to the Affordable Care Act in 2010, the Cures Act in 2016, and the Cares Act in 2020, the evolution of the provision of health care in general — and primary care specifically — has been unprecedented. These changes are only accelerating with ongoing corporate consolidation, economic pressure, COVID-19 impact, and advances in biotechnology, wearable technologies, and use of artificial intelligence in health care.

In the midst of all this, the answer to the question “Are you employed?” has gone from a coinflip in the early 2000s to 73% of family physicians being considered employed in 2021, including 93% of new residency graduates.¹ This means the vast majority of us are now contracted by a larger organization, such as a single-specialty or primary care group, a larger multispecialty group or health system, or a health insurer. Recent surveys indicate this trend is not unique to our specialty.^2,3

Our intention with this article is not to speculate whether these changes are “good” for family medicine, individual physicians, or our patients. Rather, this article addresses skills that most of us never learned during our training: how to be employed “well.”

HOW WE GOT HERE AND A WAY FORWARD

In the early days of the movement toward employment in the 1990s and early 2000s, the foundational impetus for physicians was to gain negotiating leverage with insurance plans.⁴ While this is still relevant, recent motivations for employed practice include having more regular work hours, a predictable salary, less up-front financial risk, call coverage, a benefits package, the opportunity to pay off loans, an electronic health record (EHR), improved support for quality initiatives and care coordination, a potential subspecialty network, and someone to manage staffing. Additionally, employed practice often provides additional staffing and resources to assist with prior authorizations of medications and procedures, referrals, medication assistance paperwork, and form completion. With each benefit of employment come trade-offs in terms of autonomy, control, flexibility, and influence. If a physician’s idea of being employed is simply to be provided a salary (or compensation model), building, manager, and staff and then be left alone to practice autonomously, they will likely not find themselves employed “well.”