Surgeons Choose Hospital Employment Over Private Practice

Laurie Barclay, MD

December 17, 2012

General surgeons and surgical subspecialists are opting for hospital employment over private practice, according to a database study published online December 17 in the Archives of Surgery. The researchers found that the trend was particularly strong among surgeons who are younger or female.

Data from the American Hospital Association indicate that the number of US physicians employed by a hospital has increased by 32% since 2000, according to Anthony G. Charles, MD, MPH, from the Department of Surgery at the University of North Carolina School of Medicine in Chapel Hill, and coauthors.

To assess trends and describe characteristics of US surgeon employment, the investigators analyzed data from surgeons identified within the American Medical Association (AMA) Masterfile for the years 2001 to 2009. The researchers included surgeons who were active, nonfederal, and nonresident physicians younger than 80 years, identified using definitions from AMA specialty data and the American Board of Medical Specialties certification data.

From 2001 to 2009, there was a decrease from 48% to 33% in the proportion of surgeons who reported being self-employed in their own practice, with a corresponding increase in the proportion of employed surgeons.

Moreover, there was a 32% relative increase between 2006 and 2011 in the number of surgeons in full-time hospital employment. The authors note, however, that this was an absolute increase of just 1.2%, from 9586 in 2006 to 12,626 in 2011.

At present, 68% of surgeons report being employed as their practice environment.

The trend toward employment in large group practices was particularly prominent among younger surgeons and female surgeons. Urban and rural practices showed similar employment trends.

"General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice," the study authors write. "The trend denotes a professional paradigm shift of major importance."

Factors driving this trend, according to the study authors, include the complex corporate environment, high costs of malpractice insurance, difficulties in obtaining reimbursement, administrative duties, and general risks and burden of solo or small group private practices.

Limitations of this study include possible overestimation of group practice surgeons who are "employees" because data on physician ownership interest are no longer available from the AMA.

In an accompanying invited critique, Lena M. Napolitano, MD, from the Department of Surgery at the University of Michigan in Ann Arbor, notes additional limitations: About 30% of surgeons could not be categorized because of insufficient data, and several surgical specialties were characterized as general surgery, such as hand, oral/maxillofacial, pediatric, trauma, transplant, cardiovascular, vascular, surgical critical care, and surgical oncology.

Dr. Napolitano notes that there may be financial reasons for the trend. "In the current era of health care reform and the promotion of accountable care organizations, a hospital-physician integrated system is better positioned to reap benefits than the private practice independent physician," she writes.

Regardless of the employment status, Dr. Napolitano concludes that the patient must remain paramount. "Quality of patient care must still be the prime focus of our surgical practices, and surgeon champions should lead the quality-of-care efforts, even as hospital-employed surgeons."

The study authors and Dr. Napolitano have disclosed no relevant financial relationships.

Arch Surg. Published online December 17, 2012. Abstract