For Michael Wood, MD, San Angelo was initially just going to be a place to stay for four years to pay off medical school debt.
The Florida-raised, North Carolina-educated physician had no West Texas roots. As he finished up his residency at UT Southwestern Medical School in Dallas, a recruiter introduced him to an opportunity 250 miles to the southwest. He now says he’s ready to stay in the county seat of Tom Green County for the rest of his professional career.
That change of thinking only happened because of his employment at Shannon Health in San Angelo, Dr. Wood says. Initially brought in as a hospitalist, he is now chief medical officer for the health system, overseeing approximately 400 physicians, nurse practitioners, and physician assistants. He says his setup as an employed doctor has freed him and his colleagues “to do what they love most” – see and take care of patients.
Dr. Wood says the structure is unique in that 98% of physicians are employed by Shannon, which itself operates in a unique way: The locally governed nonprofit health system was founded by a trust in the 1930s by the Shannon family and unlike other hospital systems, does not have a typical taxing district to fund its operation; the trust covers all operating costs.
“What has kept us [in San Angelo] has been how great not only the system has been in terms of the quality of care we provide and the support, but also the community too,” Dr. Wood told Texas Medicine. “The patients are just so appreciative. The relationships both with our patients and our fellow medical community are great.”
Amanda Mohammed-Strait, MD, also found an appreciation for community as a family medicine physician at Oak Street Health in Dallas, where she doesn’t see herself “anywhere else at this time.”
She has been practicing at the value-based care primary care center network for four years, mostly caring for Medicare patients.
When she finished her residency at UT Southwestern, she says she was trying to make sure she had some form of employment. Starting an independent practice at that time would have been too steep of a challenge.
After working in urgent care for three months, she signed on with a private family medicine practice, but found the dozens of patients she tended to daily to be unsustainable. In her current setting, that number is in the teens.
Her employer provides other resources, like scribes, that “make a huge difference in terms of being able to realistically accomplish things that you set out to do for each patient,” Dr. Mohammed-Strait said.
Drs. Wood and Mohammed-Strait are among the 73% of Texas physicians who, as of January, are employed, according to a report by the Physicians Advocacy Institute (PAI) conducted by the health care business consulting firm Avalere. Nationwide physician employment tops 77%.
Following the onset of the pandemic in 2020, there was a sharp increase in physician employment and hospital and other corporate practice ownership. Some physicians could not sustain the financial pressures brought on by the pandemic and sold their practices to acquiring entities, according to PAI. Over the past five years, the institute’s national research shows that hospital systems and other corporate entities such as private equity firms, insurers, and other businesses started to drive health care consolidation by acquiring physician practices.
In 2019, Texas’ physician employment was around 50%. Not long before, sensing the shift away from independent practice, TMA started an employed physicians workgroup to help develop resources for doctors shifting to employment.
That set the groundwork to help not only physicians in transition, but also those like Houston neurologist Eddie Patton, MD, coming out of residency.
“I was coming out of fellowship, so I still needed some time to build my referral base and build my network,” said Dr. Patton, who went on to work for three health systems and served on TMA’s employed physicians workgroup. The past president of the Texas Neurological Society and alternate delegate for the Texas Delegation to AMA says start-up costs 12 years ago when he started practicing were a deterrent to launching his own practice.
“When we talked about this 10 years ago, [employment among physicians] was a lot newer,” Dr. Patton said. “We didn’t really know what we needed or really know how TMA could help because a lot of these issues were coming up with EHRs (electronic health records) and administrative burdens – we didn’t really have the same issues that maybe the private independent doctor has. That was the point of us forming.”
Also, as a result of feedback from the work group, TMA has honed its advocacy for employed doctors, according to PAI vice president and TMA CEO Michael Darrouzet. TMA continues to defend its strong Texas’ corporate practice of medicine prohibitions that, unlike most other states, outlaw lay corporations from practicing medicine or directly employing physicians to provide professional medical services, and instead, put physicians between patient care and corporate lay people.
“We [continue to look] at quality issues, payment issues, relationships with [health] plans – all these kinds of things that are so different” for employed physicians, he told Texas Medicine.
With all employed situations, “there is a certain amount of autonomy you are going to have to give up, so if you go into it knowing that then you’re a lot better off,” Dr. Patton cautioned. However, physicians “are still driving the system. No patient would be admitted to the hospital, no MRI would be read, no medication would be prescribed without the physicians. And each system does have a unique culture, so [before going in] it’s always good to talk to people and see what the culture is.”
Dr. Patton, who has helped lead CME to educate physicians on career planning, adds that what still holds true today is to set up doctors for success early.
Finding the right practice setting as an employed doctor also means doing all the homework on the front end during the job search, such as making sure contract language is clear and unambiguous and understanding the compensation models.
“TMA helped when it came to things like [general educational resources on] contracting,” Dr. Patton said. “I’ll be honest with you, in the beginning, I didn’t really think about things like noncompete clauses and all the things that are within a contract. Now physicians really need to understand what these things mean … you may have to uproot your whole family if a relationship never works out.”
But employment was just the start of his journey. The experience, he says, helped put him on a trajectory to join a private practice this year.
“If you understand the different practice models it can help you choose what model is right for you,” Dr. Patton said. “When you talk about burnout ... a lot of it is because you’ve chosen the wrong [practice] model that fits you.”
Physician burnout is an epidemic in the U.S. health care system, with nearly 63% of physicians reporting signs of emotional exhaustion and depersonalization at least once per week, according to the American Medical Association (tma.tips/Burnout).
While many factors contribute to burnout, the cause is often associated with system inefficiencies, administrative burdens, and increased regulation and technology requirements.
Physicians considering employment may decide “they don’t want to deal with the capital issues,” raising funds for starting a practice or purchasing big-ticket items such as an EHR, Mr. Darrouzet said.
At Shannon, Dr. Wood says his physicians have access to a costly electronic health record system that, along with additional new generative artificial intelligence based documentation assistance platforms, eases paperwork and follow-up with patients. It also helps set physicians up for success as value-based care initiatives proliferate.
From a physician’s perspective, “it’s about OK, what’s your priority? Do you want to get out on time or get out early to go to your kid’s baseball game or do whatever it is that you’re passionate about outside of work?” Dr. Wood said.
As a system administrator, he also looks at “what technologies can we harness on an organizational level to accomplish that?” as well as other opportunities such as CME and wellness initiatives – all areas he says contribute to Shannon’s high retention rate among its employed physicians.
“What I’m focused on is helping our physicians do what they love most, which is see patients and take care of patients. So not having to worry about the billing and the collections and the administrative tasks on the business side I think increases [doctors’] quality of life.”
For Dr. Mohammed-Strait, quality of life comes in the form of knowing, as a mother, that your employer has your back if family life needs tending to.
“I’ve had many times in the last year where I’ve had to pick up and go,” she said. “Not only does my team support me, as well as my other colleagues, but also my upper management does. They’re like, ‘Listen, we get it, just go, we’ll take care of things later and just make sure you’re good, your family’s good.’ That takes a huge load off.”
She also has her employer’s support for the community outreach programs she finds fulfilling as a member of TMA’s Council on Health Promotion, such as Walk With a Doc and Hard Hats for Little Heads.
“I really wanted to implement a community aspect to my position at my current employer, so I advocated for that, I showed the benefits of why that would lead to better outcomes for patients, and they listened to me,” she said. “Having people who are also willing to navigate with you and stretch themselves in maybe ways that they didn’t think were possible or could be a benefit to the organization at large, is important, too, so [find out] if they’re listening to feedback.”
For Cynthia Jumper, MD, being in an employed setting means building a “legacy” in her hometown as an educator.
The vice president for the Texas Tech University Health Sciences Center Lubbock knew in medical school she wanted to play a part in the growth of health care in the South Plains since she started on faculty in 1995. Enrollment at TTUHSC has grown 18% from 2012 to 2022, according to the school.
“I’ve really seen the effect it’s had,” Dr. Jumper said. “I went through public school here, and it’s very important for me to stay in my hometown, take care of my family and my friends and to watch what health care can do.”
Working for TTUHSC, Dr. Jumper loves the “variety and challenge” she gets to do every day that physicians working in small practices or corporate settings don’t have.
“I may be occasionally overwhelmed, but I’m never bored,” the pulmonologist said. “I’m building a curriculum. I’m seeing patients. I’m writing research articles. I’m applying for grants. I’m doing administrative tasks. I just never thought private practice – going into a clinic every day – was what I thought about being a physician.”
As a 38-year member of TMA and board trustee, Dr. Jumper has seen what the association also has done to help her colleagues in academia, particularly in growing graduate medical education, and Texas’ workforce as a whole.
“That’s really helped [academia] now downstream and helps the private [practices] because most of my graduates go into private practice,” Dr. Jumper said.
Dr. Patton used his experience over 10 years as an employed doctor at three different health systems to make the jump to join a private practice, adding that TMA is here to continue to help educate all members on the business aspects of various practice settings. He loves the fact that the association now has an annual Business of Medicine Conference, scheduled for October (texmed.org/BMC).
“With just a little bit of education from organized medicine and TMA, you can ask the right questions and then at least push you in a little bit better position to feel stronger as a physician … to [make a more informed decision when choosing] ... the right model for you,” Dr. Patton said.
Dr. Wood adds he might not have found San Angelo had he not considered alternatives – a recommendation he makes especially as the vast majority of physicians move jobs within the first few years of practice, which can be disruptive.
“So, if you say, ‘Well, I’m in Dallas; I’m just going to stay in Dallas,’” he said. “For some people that’s great, but consider: ‘What if I went to a different practice setting? What if I cast my net wider?’ You might find a gem of a practice setting. So, get your last job first.”