Why Be Independent?

Today I had lunch with a very nice medical subspecialist who is in the the first year of setting up his independent practice, having practiced privately for five years in the Midwest out of fellowship, and then with an integrated group here in Northern California. Naturally, I asked him why he was going into independent practice. He said that he had a streak of entrepreneurialism in him, and that he didn't want to answer to a boss. Good reasons. His colleagues around the hospital here have been telling him he's crazy, that he'll never make it, that he should rejoin a network. I told him they were the ones who were nuts. If he has a vision, ambition, energy, and intelligence, and some good luck, even though he doesn't yet quite know what he's doing, he'll do very well, very well indeed. There will be a place for an sbuspecialt center of excellence. There is always room at the top.

During the conversation he talked a little about what it was like to work in the network, by way of explanation of why he wanted to be independent. He said that the large group established smaller groups of five or six doctors in each locality and put one of them in charge, not particularly because that doctor was the best or chosen by peers, just appointed by administration to be in charge. His local chief reviewed charts and told him that his charts needed to be better. He thought, what about yours? Are yours any better? Where do you get off?

I told him that that was why I had been independent. I didn't want to answer to someone who wasn't as smart as I was. Plus, of course, I'm entrepreneurial, too.

But here was the story that struck me most. When he arrived, he was warmly welcomed and was given a medical assistant whom he trained over a six month period.  They became a well-oiled team. Then, one day, she didn't show up for work. Where was she? The administration said they couldn't call her for five days. Five days? Labor law? What was that about? They didn't tell him anything.

Then, she didn't show up for three weeks. Still, they didn't tell him anything, they just gave him “floater” replacements, medical assistants untrained for the specific job. The administration knew what was happening, but they didn't tell the most involved and affected person in the organization, him. She wasn't going to come back for months. “What am I going to do?” he asked. The answer was, live with the floater replacements.

Eventually it turned out that his MA had entered rehab for a meth problem. She came back eventually, but meth addicts don't really come back, and they didn't give him a real replacement. He was screwed.

What the administration should have done, of course, was closed ranks with him, their teammate, leveled with him about what was happening, and faced the problem and solved the problem together. They would have become closer for the experience, more trusting of each other. Instead, inexpertly, they allowed a crisis to open a gulf within the group, and eventually this led to their losing their subspecialist.

Corporatization doesn't have to be this way, with administration appointing leaders without consultation, with those leaders not knowing how to lead and how to form a team, and with administration not knowing how to work as a team when faced with obstacles. I wasn't surprised to hear about this event, but it was still dispiriting. It seemed like object lessons in poor corporate behavior. It's not inevitably this way.

Except that, it is. Yes, good organizations can exist and do exist, but mostly, these examples I heard about today are pretty much the norm, as far as I can see. Good and capable and informed and creative and well functioning and capable organizations exist, but they are the exception. And here we are in medicine, corporatizing like crazy, so that's pretty much all we'll see pretty soon.

It's really such a shame.

Budd Shenkin