Editorial by Jemshed Khan
In the eighties ASOPRS was smaller, more like a family. Spouses volunteered to assist with meeting registration. Children frolicked poolside at Spring Meetings, splashing and laughing and running. Over decades one watched them grow. Some of the generations of ASOPRS physicians that I observed included the Buergers, Schaefers, Epsteins, Rootmans, Katowitzes, Tses, Gavarises, Hollstens, Perrys, Solls, Stephensons, and Stasiors.
Studies of children who follow a parent into medicine reveal several common factors at play. The children recall visits to the medical workplace where enthusiastic coworkers asked if they planned on becoming a doctor too. The seed was planted. Inevitably, odd medical artifacts made their appearance in the home: a specimen in formalin, a bag full of sheep eyes, a glass prosthetic eye. These bizarre occurrences seemed normal in medical families.
Nature and nurture influence career choice in physician offspring. Physicians are often competitive and intelligent: both traits favor a career that demands much sacrifice and effort, but also provides ample rewards. Physician households can bankroll tuition costs that would bankrupt middle class families; Ivy League tuition can exceed $90k/year. The intellectual and emotional challenge, altruism, income, and social status associated with being a physician all motivate career choices in multigenerational physician families.
Following a parent into Oculoplastics was easier when medicine was mostly solo or small group private practice. Back then, after residency one either "hung out a shingle," or went on to a fellowship. Most preceptors were private practitioners who helped at the University. Private practice was a small business enterprise built upon personal excellence, local relationships, and patient care. The physician of that era was a highly autonomous being whose expertise spanned several domains, whose level of education often exceeded that of other health care workers, and whose judgement and skill would routinely make the difference between life and death.
Much has changed. Especially the decline in solo practice, the increasing expertise of other health care workers, and the loss of status afforded physicians. Most of all, institutional and government policy is now driven by corporate rather than public interest. Let's explore these changes and how they relate to physician families.
For millennia, human offspring worked alongside parents and acquired their skills. This specialization of labor yields profitable efficiencies or "comparative economic advantage" (Ricardo's theory). This advantage was passed down the family tree; offspring would inherit a parent's trade or practice without having to build a business from scratch. As privilege, power, wealth and skill accumulated across generations, they were subject to race and gender-based barriers. Fortunately, those barriers are breaking down. Unfortunately, transfer of business and skills across generations has become difficult because private ownership is being replaced by profit-driven corporate and institutional control. Let's examine the financialization of the medical sector; why it happened: in doing so, we can understand how medicine has changed.
Beginning with Medicare, American medicine became increasingly regulated, specialized, and bureaucratic. The real client was the third-party payor rather than the patient. Physicians responded by forming partnerships and groups to dilute overhead and centralize onerous insurance tasks. This led to formal compensation plans and detailed revenue statements.
Group practice Profit & Loss statements were the beginning of the end because they attracted the attention of venture capitalists (VC). Venture capitalists feed off surplus capital generated by inequitable Federal tax policies and obscene tax favoritism (e.g., carried interest, long term capital gains). VC examined practice profitability and began acquiring practices. They folded practices into publicly traded entities whose stock then traded at multiples of earnings. Most private group practices could not resist the immediate personal wealth generated by selling out to private equity. Thus, between institutionalization, onerous regulation, and financialization, the practice of medicine was forever changed. Given the Federal tax policies at play, physician's taxed at 40% personal rates had zero chance of prevailing against VC on such an uneven playing field.
Some private equity physicians still enjoy practice, but many find the patient load, time demands, and loss of autonomy to be extremely stressful. Many employee-physicians and university physicians have been relegated to line-worker status. They function as relatively powerless and easily replaceable widgets in a profit-driven system that is evolving to provide efficient care at the lowest cost to maximize financial return.
In some places medicine has been dumbed down to the point that the doctor just needs to perform their assigned task. Shift work. This is reflected in Medical School acceptance criteria that no longer prioritize predictors of academic performance such as standardized testing. The knowledge and judgement that physicians once held in their heads is being replaced by AI, practice patterns, and non-physician providers. Diagnosis and treatment are relegated to algorithm. The patient's perception of their encounter and of their provider is often more important than tangible health benefit. Why? Because if the patient doesn't complain, management is free to demand higher productivity and insist that doctors smile through gritted teeth. Fortunately, the pendulum always swings.
In our own field we have seen fellowship oversight outsourced to AUPO. In effect, training has been transferred from a preceptor-centered model to a department-centered model. This reflects the underlying migration of physician practices from solo to group to corporate/institutional. While this is contrary to the autonomy of our specialty, the younger generation faces a different future and seems willing to offload the administrative burden of fellowships to prioritize other unspecified goals.
The next generation of physicians will look at medicine as a less daunting occupation. They will gravitate towards definable hours and life-work balance. Medicine will become more of a nine-to-five job and less of a career. Many will favor institutional and organizational prestige over personal merit and will be required to demonstrate group allegiance rather than exceptional performance. Allegiance will shift from the patient and the profession to the employer. This is an intended and socially managed outcome designed to maximize shareholder wealth.
For sure, earlier times required a different level of commitment, a different mindset. Nowadays a career choice in Medicine is less influenced by family interests. Many young doctors aspire to executive or corporate leadership positions. Direct patient care to them is menial. Despite all of this, I would never discourage a career in medicine. It is a broad enough field that one can still carve a rewarding and challenging personal path while providing excellent personalized care. Old school for sure. But how is this not the highest calling for those who wish to better the lives of others? We are fortunate to have practiced through the best of times. BACK TO Newsletter
