Originally Posted by CraigB-RN
My question is why is that autonomy important to you? I've found over the years that a lot of people really don't understand what they mean by autonomy. I've worked in places as a staff nurse were I had enough autonomy to get my self in a lot of trouble if I wasn't careful.
Even Doc's don't have as much autonomy as people think they do. They are governed by "standards of Care", There are clinical pathways that direct how a given disease process is handled,The pharmacy committee dictates what antibiotics will be available in any given facility, insurance companies have more control over things than people think they do sometimes, and the economics of the the patient limits what a doc can and can not do. And I bet if you looked at the numbers, a large percentage of Docs actually work for someone.
Is it the opportunity to open your own practice? Dave help me on this, but from what I know about practice management, it's a LOT of work and not as much patient care as you would like. Plus it's expensive, salaries, equipment, rent. Just way to much like work for me.
I admit that part of my opinion is based on what is rapidly approaching 32 years in this business and I'm pretty cynical about a lot of things.
Actually the physician ownership issue has waxed and waned. It probably hit its low point in the late 1990s when hospitals were buying up many physician practices in order to steer patients to particular hospitals. As most people would expect hospitals proved to be spectacularly bad at running physician practices. I saw one study that showed hospitals lost on average almost $100k per physician in practices that were purchased by hospitals.
On the other hand there has been a increase in either publicly or privately held firms entering as medical management firms. These are very common among hospitalists, EM, and anesthesia. There are still a number of hospital owned practices in the East but seem to be less popular in the west.
Center for Health System Change has data (relatively small N but reasonable for trends) that tracks physician practice data for the last 10 years or so. It can be found here:
http://ctsonline.s-3.com/psurvey.asp
Data there shows that around 50% of practices are owned by the physicians themselves (owned defined as full or part interest in the practice).
This mirrors data from 1996 found in this abstract in JAMA.
http://jama.ama-assn.org/cgi/content/abstract/276/7/555
MGMA data is similar here. So I think that around 50% ownership is about right. If you look at the salary data for physicians, almost without exception those practices that are owned by physicians are the most lucrative. In addition specialists are less likely to be in non-physician owned practices (which tend to be the most lucrative practices). Surgery is also less likely to be non-physician owned. The caveat here is that hyper specialties (ie neurosurgery subspecialties) tend to be university employees.
To be honest one of the primary reasons that I chose not to go to medical school is that I had no desire to run a business. I have had the opportunity to work in three different practices in the course of my career and observe many more. There are a few physicians that are good at business (and a similar number of PAs and NPs). I think intrinsically it is hard to be good at both. Invariably the physicians that go into business do less and less medicine (look at the recent CEOs of almost any large insurance company). The best practices put someone schooled in business in charge of the business affairs which allows them to practice medicine. The worst try to manage the business affairs like they do medicine (my first rule is never take a job where the physicians wife or husband is the office manager). The reason that half the physicians do not have ownership of their own practice is that they have no desire to run a business, they have no talent run a business or they have already failed at running a business (or a combination of the three). So over half the physicians have given up the "autonomy" of running their own business.
Next lets consider the original quote. What defines autonomy? It is classically defined as personal independence. Most definitions talk about self direction and self reliance. Under that definition there is a lot of autonomy in medicine (in the case of self direction) and very little (in the case of self reliance). If you doubt this try to order a CT. The CT is very easy write an order and it will generally get done. On the other hand from a self reliance standpoint you would have to buy a CT, get a license to run it, hire the people to maintain it, learn how to read CTs .... you get the idea. Medicine is by definition a team sport.
As far as self direction in medicine as Craig-B stated there are a number of guidelines and clinical pathways that may or may not influence what you do. Standards of care are also a "drag" on self direction. As an employee the practice will have an interest in making sure that you do not put the practice at risk. An employee (be it physician or NPP) will be more restrained than an owner but even owners are not allowed to put the practice at risk. The consequences of action here are more severe than that of an employee (loss of ownership).
Finally consider the other costs of "autonomy". Lets say you define autonomy as owning your own practice. One way of doing this is to do everything yourself. You make appointments, room the patients, bill for the visits etc. At this point you are in charge of your destiny but you are probably spending more than 1/2 your time doing non medical things. That is the price of independence (although there are a number of physicians practicing this type of Concierge medicine).
The other way is to open your own practice. In the standard model you have at least an MA and a front desk person. Now you have two people depending on you to bring in the bucks as well as pay the rent keep the lights on etc. Now lets say you band together with some other practitioners to gain efficiency. Oops there went the autonomy.
Bottom line as CraigB stated running a business is hard work. There are few people that are good at it. There are less that are also good at medicine. Remembering that less than 50% of new small businesses are around in 5 years helps bring this point home.
In my mind autonomy is finding an environment that allows me to utilize my knowledge, improve my skills with minimal distraction and good support. This is my way of looking at things. Of course I've always been about the journey not the prize
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As my usual standard of desperately trying to make this somewhat pertinent of the actual title of the thread. I am assuming the comment by Star77 was a reference to more perceived clinical autonomy for NPs vs. PAs. If you look at the number this is not supported. The number of PAs in independent practice is pretty reliably put at around 2% (independent practice defined as ownership of the practice). The data for NPs is not as good but the Advance for NP survey put the number of NPs at exactly the same percentage (it will be interesting to see what the AANP data set says). So there is no real advantage from a clinical standpoint (defining automony as practice ownership). Based on my own definition of autonomy I think that autonomy is more based on the practice environment than type of certification (NP or PA). Given that in most practices PAs and NPs that work in the same practice usually have identical duties (at least anecdotally) this is further supported.
Hope this helps
David Carpenter, PA-C
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