Doctors doctoring

March 8, 2022 9:24 AM

I am trying to understand better the professional aspects of practicing medicine in the U.S.

In particular, I'd like to get a sense of the evaluation and incentive structures, and the typical progression of a career in medicine. I'm particularly interested in hearing about this for the perspective of a specialist (say oncologist) attached to a hospital, but would be interested also in how that differs from say private practice.

- Evaluation: how is performance evaluated? do patient reviews matter? professional certification? statistics of outcomes of patients treated? studies published? what incentivizes a medical professional to "go the extra mile", what does this look like and is this biased toward personal motivations? are performance evaluations made regularly or only at certain points of the career?
- Career progression: what differentiates a junior doctor from a senior doctor? is there an explicit distinction (via promotion) or is this more implicit? is career advancement determined by years of practice? number of patients? outcomes? is there a strong (external or internal) incentive to progress one's career?
- Choice: to what extent do doctors have choice in terms of location, organization, support (nurses or administrators), or patients? Once chosen, is it moderately difficult to change?

Thank you in advance for your insights.

posted by dragonfruit to Work & Money (3 answers total)

Best answer: There’s two different tracks to think about here, academic vs clinician only. Often when people say private practice they mean a doctor who practices medicine outside of academia, but in reality most docs in the US are not really in private practice but are, as you point out, “attached” in some way to a hospital.

For academia, evaluation is based on many of the factors you mention. Publications, presentations, reputation among other physicians as being good at what they do, etc.

In clinical practice-only world, there isn’t much evaluation. In my three years of practicing after residency, I have yet to have a performance evaluation that I have been made aware of. There are patient satisfaction scores but administrators don’t care about these unless they are egregiously and consistently terrible.

Things like closing your notes on time are tracked by administrators. (The quality of those notes is not.)

My earnings are related to number of patients I see, and there is some pressure to see as many as possible. Patient outcomes are known as “quality metrics” and this related to, for example, how many of my patients with a certain diagnosis get a certain test every year, or how many of my patients with a certain diagnosis get a prescription for a class of medicine known to help with that diagnosis. At my institution, quality metrics determine bonuses. So for me, if I see a minimum number of patients, I then qualify for a bonus based on meeting quality measures, some of which I have control over snd some of which I don’t, and none of which relate to “going the extra mile” for a patient.

Seniority is based on how many years in practice, and also willingness to do things (for free) such as be on a hospital committee or be the “lead physician” of your group, which entails attending meetings, being point of contact with administrators, and in theory but not in practice conducting performance evaluations of others in your group.
posted by amy.g.dala at 11:42 AM on March 8, 2022

Best answer: I re read your question and see I didn’t answer the part about choice. I am answering this question based on my employment situation, which is an employed physician (ie not in private practice), all clinical (ie no academic or admin responsibilities), outpatient group practice affiliated with a big hospital system.

I can absolutely choose where I work. I feel like I’m in high demand and after residency, interviews felt like a formality. I could quit and find a job in another location tomorrow.
I also have the freedom to practice how I want, up to a point. I can do or say or recommend anything I feel is appropriate when it’s just me and the patient in the room (or telehealth session, which I’m…say…95% sure is not being recorded).
That’s where choice ends. I have no say in terms of hiring and managing medical assistants, nurses, office managers, front desk staff, etc. I can make suggestions about their work and work flow etc, but these would be suggestions only. As far as choosing patients, I have to see whoever calls to make an appointment. We can dismiss patients for cause, for example if they yell at our front desk staff one too many times or if they violate a controlled substance agreement.
posted by amy.g.dala at 11:53 AM on March 8, 2022

Best answer: Note this is about community physicians, not really academic.


Evaluation: how is performance evaluated? Sometimes by hospital metrics, sometimes Medicare, sometimes both. Examples: clinical outcomes (which is often crap because we can’t go into patients homes and make them eat healthier), how full your clinic is, how many intakes you do, how often you cancel/reschedule patients, how quickly you respond to patient messages, involvement in meetings, committees, etc.

Yes, pt reviews do matter for some specialities. Read about Press Ganey.

Incentives to go the extra mile? Usually money or to get admin off your back or extreme masochism you haven’t worked out yet in therapy. If your bonus is based on metrics like the above, then you’ll often get a quarterly report of how you’re doing.

Career progression— this usually means getting into leadership, being a medical directors etc. but while medical director may sound nice, it is often extra admin work without commensurate pay (and being the bad guy making burnt out doctors run even faster on the hamster wheel to satisfy the corporate MBA master douchebags who invented many stupid metrics that are all about $$$ and nothing to actually do with the welfare of the patients or the doctor). I’ve seen people become medical director a couple years out of residency.

Doctors have a lot of choice in terms of location, organization they work for. Patient population maybe. Support staff depends on what the hospital/clinic wants to pay for (usually not much).
posted by namemeansgazelle at 4:48 PM on March 8, 2022