Medical Practice Divorce: Successfully Managing a Medical Business Break-up
PSYCHOLOGICAL PREPARATION FOR CHANGE
Peter S Moskowitz, MD
The past twenty years brought profound changes to American medicine that continue to impact physicians professionally and personally like never before. As a direct result, the practice milieu, the emotional profile, and the coping strategies of physicians are undergoing change. Career dissatisfaction is growing and widespread. Increasing stress and burnout, substance abuse, medical disability claims, premature retirement, and alternative career planning by physicians are secondary signs of the growing crisis in American medicine.
For many physicians, the current climate will spur a decision to leave or relocate their medical practices. The focus of this chapter is to assess the factors that contribute to a decision to leave or relocate a medical practice. The ideas presented here emanate from experience with several hundred physicians who have attended physician renewal workshops or who have sought career and life coaching assistance.
CIRCUMSTANCES LEADING TO PRACTICE DISSATISFACTION
For decades the practice of medicine in the United States offered remarkable career stability. Steadily increasing demands for fee-for-service medicine and high levels of public esteem for physicians produced high levels of career satisfaction among physicians. Rigorous training was offset by an unwritten guarantee of high income relative to other professionals, broad public respect, and unprecedented practice autonomy. Physicians were the captains of the health care industry’s ship. Health care income, as a percentage of the gross national product, rose steadily. Few could foresee a potential need for change.
A complete discussion of the reasons for the change in this previously stable pattern is beyond the scope of this chapter. However, suffice it to say that the advent of managed care in the mid-1980’s started a chain reaction that has permanently altered both the structure and function of the medical establishment. Over time, the work of providing healthcare services has evolved in specific ways that were unforeseen both by physicians and by provider organizations.
The development and management of large multinational health care systems, mergers and consolidations, managed-care contracting, and increased competition among individual providers and systems of providers have permanently shifted much of the balance of control from providers to managers and from local sources to regional, national, and international systems. Managed care, including discounted fees for services, health maintenance organization/preferred provider organization (HMO/PPO) contracting, and capitated contracts, have driven physician reimbursement to significantly lower levels. Managed care has also resulted in longer service hours, shorter per-patient contact time, and limitations on the selection and availability of diagnostic tests, therapeutic services, and pharmaceutical products. Often, decision-making is done by others with significantly less professional training and expertise than physicians. Many physicians believe that the new rules degrade their ability to provide high-quality care.
As a result of this revolution in health care, the typical physician has become more like an employee, with significantly less autonomy and control, less desirable working conditions, and faltering income. The result is stress. The new rules and demands of managed care have pushed thousands of physicians over the brink into feelings of depression, anxiety, powerlessness, and inability to cope. Unless significant efforts to improve self care and stress management are made, professional burnout often is the result.
Reliable figures for incidence of burnout in the medical profession are difficult to procure. A recent study conducted by the Sacramento-El Dorado Medical Society revealed a startling incidence of burnout among physicians in northern California. In that study, 66% of physicians agreed that burnout posed a problem to patient care, 75% agreed that burnout posed a significant problem within their own practice group, and 40% admitted to being burned out themselves. The actual incidence of burnout I probably higher than these percentages suggest.
Factors other than stress and burnout often contribute to or are primary reasons for changing practices. These are discussed later in this chapter (see the section, “Primary Causes of Medical Practice Transition”).
UNDERSTANDING COMMON PHYSICIAN TRAITS
Although it is hard to generalize about the personalities of all physicians, studies have revealed certain personality traits that are common among physicians.2-4 Understanding these common traits may help to predict their responses to stress and their coping strategies.
Physicians tend to be driven and perfectionists. They are idealistic, hard working, dedicated, intellectual, and serious. Their ego satisfaction is often derived only from work and career, which explains physicians’ relative lack of involvement in hobbies or interests outside of medicine. Through years of difficult training, they have learned self-sacrifice—to deny their needs while caring for others. Physicians often insulate themselves from their own emotions, and often they are isolated socially, with few intimate friends and few friendships outside of medicine. This often leaves them locked into their own thinking patterns with little emotional support or access to objective feedback from others.
Ironically, although most physicians are sensitive and caring of the needs of others, they do not always nurture or take particularly good care of themselves physically, emotionally, or spiritually. Fiercely independent, intellectual, and curious, they usually have an overdeveloped sense of responsibility, which fuels their tendency toward overwork and denial of their own needs. Despite their remarkable level of professional and personal success, physicians tend to be insecure and excessively self-critical.
Physicians’ intelligence, independence, work ethic, integrity, and empathy serve them well as healers, yet their isolation from self and others often becomes a source of deep loneliness both within and outside their primary relationships. Because of their independence, pride, and perfectionism, most physicians are reluctant to admit neediness. They avoid asking for help until or unless they are in crisis. Because their comfort level gravitates toward stability, control, and predictable outcomes, they become uneasy and anxious when face with change or loss of control.
Relying on this profile, it becomes easier to understand the current professional and personal crisis rampant among health care professionals. Unequipped to manage change, lacking plentiful social outlets for support and feedback, some members of the medical profession are anxious and fearful. They are reluctant to admit distress or to ask for professional help, considering it a sign of character weakness. Because they take poor care of themselves, physicians who make efforts to manage their own stress more effectively—by taking more time off or by working shorter days, for example—often also provoke feelings of guilt and shame. Concern about the success of their short-and long-term financial goals in the face of falling income contributes to their reluctance to reduce their workload. Paradoxically, some physicians may decide to work harder in a desperate attempt to stabilize income and to escape their increasing anxiety, only to find themselves emotionally, physically, and spiritually bankrupt.
The time-honored methods many physicians use to deal with stress and job or family problems are intellectualization, denial, avoidance, and work. Given an issue to resolve, physicians will typically turn first to their strengths: logic and reasoning. They will often seek solutions that require the least personal effort, and they may prefer to delegate responsibility to others. Still unsuccessful, some may choose to avoid confrontation with the hope that the problem will resolve itself spontaneously. Others may deny that there is a problem or try to resolve the problem through additional brainstorming about a solution. Blaming others for lack of success is common.
Such traditional coping strategies as asking for help (from friends, co-workers, or a professional), engaging in physical exercise, seeking emotional support (through psychotherapy, counseling, or peer groups), spiritual renewal (prayer, meditation, journal writing, or spiritual counseling), hobbies, increased rest, and relaxation are selected far less commonly by physicians.
PRIMARY CAUSES OF MEDICAL PRACTICE TRANSITION
The primary causes of medical practice transition include stress and burnout, lack of life balance, physical illness and disability, behavioral disability, and skill-reward mismatch.
STRESS AND BURNOUT
Stress and burnout have become major occupational hazards for physicians. Although the problem has long been recognized, solutions are not always readily at hand.
The reasons provided by physicians for their own burnout are similar from one study to another. 5-7 In descending order of frequency, they include decreasing practice autonomy, loss of control in decision making, increasing work load, the encroachment of managed care, and declining income. By nature, most physicians are more comfortable in environments in which they can control workplace variables. To a large extent, managed care has removed them from this position of control. Not only is this a source of chronic stress, but also physicians are frequently not empowered to alter their circumstances with respect to managed care.
Another factor playing a role in burnout is the limited coping strategies of most physicians alluded to earlier in the chapter. Many physicians tend to deny their own stress and the feelings generated by the stress. Many feel guilty about their feelings of frustration or anger about their career, problems related to patient care, or their own emotional or physical limitations at work. For many, coping means working even harder in the hopes that in so doing, they will become too busy or too tired to have to deal with their own negative feelings.
What can physicians do? Those who suffer from stress might first focus on those issues causing the stress, and then strategize about only those stressors they can change. Some have found it helpful to make a list of the aspects of work that drain their energy and a list of those aspects that energize them. Finding ways to do less of the former and more of the latter is a simple formula to lessen work-related stress.
LACK OF LIFE BALANCE
Almost without exception, the most important factor missing from the lives of most burned-out physicians is BALANCE. Developing better life balance is the most potent insulator against physician burnout and can restore personal and professional resilience.
Unfortunately, life balance is rarely present in the lives of busy physicians. Many physicians do not have a clear vision of what life balance entails or, even if its value is apparent to them, how to acquire it. Many have lived their entire adult lives out of balance, believing it is the price they must pay to follow their calling to the practice of medicine.
Life balance means many things to many people. Following is a description of six domains of balance: physical balance, emotional balance, spiritual balance, relationship balance, community balance, and work balance.
PHYSICAL BALANCE. People with physical balance have good cardio-vascular and neuromuscular conditioning. They are in good health and have abundant energy.
EMOTIONAL BALANCE. People with emotional balance are generally calm and centered. They are able to accept positive and negative input without excessive mood swings. They are aware of and are able to manage their feelings.
SPIRITUAL BALANCE. People who have spiritual balance have a feeling of connectedness to self, to a community, and/or to a power beyond themselves. They feel a part of a greater whole and are hopeful rather than fearful.
RELATIONSHIP BALANCE. People who have relationship balance are able to receive in their key relationships in proportion to what they give; they are comfortable sharing their own needs, wants, and reality with significant others.
COMMUNITY BALANCE. People who have community balance have a relationship to a community of people who have similar interests. They give to that community of themselves in proportion to what they receive from others in that community. This satisfies the basic human need to feel a part of a community, and creates energy, gratitude, and selflessness.
WORK BALANCE. People who have work balance are able to give of themselves at work enough to be valued, to succeed, to advance and to be challenged without losing their own sense of self or their own values.
Acquiring life balance first requires that people become aware of the absence of balance in their lives. During their training, denial of emotions and of physical and emotional needs becomes a survival tool for physicians. In medical school or even earlier, physicians-in-training are taught directly and indirectly to “work until the work is done,” and to be sufficiently emotionally and physically tough that their own emotions or physical needs do not interfere with duties to patients in times of emergency or crisis. As a result, physicians learn to perceive and solve problems around the needs of others, but not with regard to themselves. Although these skills serve physicians well in times of crisis, eventually many physicians shut down access to their own emotions so effectively that they are unable to be intimate or unguarded with themselves or with others. Not until the pain of their own isolation and loneliness becomes a problem, until their key relationships begin to fail, or until their physical health fails will some physicians reach out to seek help in improving the balance in their lives.
The equation to reach lifestyle balance will be unique to each person. A dynamic equation that will change over time, it will consistently lead to a greater sense of well being. To acquire better balance, physicians must learn to assess their needs in each domain on a daily basis. Self-awareness may come from a daily practice of listening to one’s inner voice through prayer, meditation, journal writing, or quiet time alone. Over time, as balance and happiness develop, physicians often find that the value that they attach to this time alone increases. They learn that balance often results in their wanting what they already have—or, if not, it results in a decision to change those things that are under their control to get what they want.
Maintaining balance also requires that physicians assess their personal values and integrate those values into their daily lives. Balance requires integration of values, career, and private life to reinforce one’s values and to spend as much time daily satisfying one’s domain requirements simultaneously. Doing so may necessitate a minor or major career overhaul.
Balance in life is not obtained easily. It is especially hard for physicians whose education and training have consistently emphasized the value of doing and achieving over the value of just BEING. With this orientation, work may become the sole source of ego satisfaction and personal identity.
As discussed earlier, work often becomes a coping tool for stress. Achieving balance is also difficult for physicians because they are often socially isolated, with few intimate friends. Without such friendships, physicians may have no consistent source of objective feedback relative to their values, choices, and behavior.
Pitfalls in achieving lifestyle balance include the following:
The assumption that balance will be easy to obtain;
A lack of personal commitment or a suitable support network, or both;
A tendency toward perfectionism that may result in procrastination;
Isolation that may result in being locked in one’s own thinking patterns;
Over-commitment that distracts the physician from giving adequate attention to his or her own needs;
Preexisting addictions that support unhealthy lifestyle choices and that foster imbalance; and
Financial overextension, poorly informed financial decisions, or an expensive lifestyle that is difficult to scale down.
PHYSICAL ILLNESS AND DISABILITY
A physical ailment or disability commonly is the signal that immediately precedes a career or life transition for physicians. Physicians are not immune to diseases, and because they live and work under great stress, they are at great risk for disease. Although primarily an issue for mid-to-late-career doctors, it obviously may occur at any age. Recent evidence indicates that disability claims to insurers by physicians are rising at an alarming rate.8-10 This dramatic rise is related largely to emotional disabilities, including depression and anxiety disorders.
Systematic health issues forcing transition may include such acute events as coronary vascular disease, stroke, and trauma. Chronic illnesses may include malignancy, neurologic disorders, gastrointestinal disease, and arthritis.
Physical disability often necessitates modification of the workplace. This may include reduction in work hours, patient case load, night or weekend call duty, practice management responsibilities, or some combination of these. In the case of more severe physical disabilities, retraining in another clinical discipline or transitioning from primary case to practice management or administration may be appropriate. These issues and strategies can best be developed and implemented with the help of a professional career coach or counselor.
As discussed previously, ample evidence exists that the changing medical environment is taking a toll on physicians’ emotional stability. It is a tribute to the profession that so many doctors function so well under the conditions in which they work. A steadily increasing number of them, however, are ceasing to function effectively because of underlying or acquired mental disability, or both, which may include depression, anxiety disorders, bipolar illness, other psychiatric disorders, and chemical dependency. All may be exacerbated by stress. There is evidence that disability claims for emotional disorders are rising rapidly in the physician population; and monitoring agencies suggest that the rates of physician impairment from such disorders are rising, except for the rate of chemical dependency, which is stable.11
During recent years, interest has focused on the growing problem of behavioral disorders as exemplified by what is commonly termed the DISRUPTIVE PHYSICIAN. Such physicians come to the attention of hospital medical staff committees and county medical societies because of their aggressive or hostile behavior toward other health care professionals or patients in the work place, or both. They repeatedly exhibit unpredictable, uncontrolled rage in conjunction with abusive language. The behavior pattern is pervasive despite verbal and written warnings and disciplinary threats. Disruptive physicians also experience a significantly higher rate of malpractice litigation.
Extensive evaluation of large numbers of such physicians has revealed a significant incidence of underlying axis I psychiatric illness and/or coexistent substance abuse and other addictions.12 Frequently, affected physicians may have a history of severe childhood emotional trauma and significant adult career or life stress. Prognosis for improvement is good provided that appropriate professional intervention and treatment occur. Without intervention, recurrent job loss, reprimands, censures, and lawsuits may ensue. These setbacks frequently cause multiple career transitions unless or until the personal problems are addressed effectively.
An often over-looked source of career dissatisfaction and transition is the mismatch between skills and rewards. SKILL-REWARD MISMATCH refers to a physician’s discovery, over time, that his or her particular medical skill set is not being adequately recognized or rewarded in the workplace. The problem may be that the particular skill set already exists or is over-represented in the local medical community. It may be that the physician’s practice partners do not provide appropriate recognition through feedback or referrals; or financial remuneration may not reach regional or national norms. Regardless of the reason for the discrepancy, resentment is the byproduct of skill-reward mismatch. Resentment is a potent caustic that increases stress and erodes collegiality within a professional practice partnership.
What constitutes adequate reward is a highly individual equation that may change over time. Once recognized, mismatches must be analyzed from the perspective of whether or not adequate reward is a reasonable expectation, given the reality of the situation and the dynamics of the community. Although purely financial mismatches may be improved with dynamic marketing, nonfinancial mismatches are more difficult to rectify. The latter should raise a red flag suggesting the potential need for transition or relocation. Candid discussions with practice partners and referring physicians, while awkward, may provide objective feedback and improve communication between partners to resolve skill-reward mismatches. Many successful medical groups make time for such feedback at regular practice retreats.
MISMATCH OF EXPECTED AND ACTUAL WORKLOADS
Managed care has resulted in significant increases in the intensity of patient contacts per physician work unit in all clinical practices. This rise is particularly true in multispecialty clinics and HMO practice settings. For many physicians whose professional and personal life balance has been marginal, this change alone has been the factor to overwhelm them, leading to stress and burnout.
Work volume expectations when the physician first entered practice may have become among the most difficult obstacles preventing physicians from creating optimal work environments for themselves. However, falling income does not imply the need for practice relocation. Downsizing one’s practice and lifestyle expectations can be important tools for coping instead. VALUES-BASED FINANCIAL PLANNING means, in simple terms, that the physician and his or her spouse work together to discuss and prioritize what is most important to them as they think about their future. This process should consider what attitudes, assets, comforts, lifestyle, work plans, and financial responsibilities they desire or anticipate, and then designing a financial plan that assures they will have sufficient resources to meet those goals. It contrasts to the planning technique of aiming for a specific lump sum of money in order to reach “financial independence.” (See Chapter 3, “Financial Planning to Ease Your Exit,” for a detailed discussion of this topic.)
OTHER CONTRIBUTING FACTORS
Additional factors contributing to medical practice transition include the changing workplace environment, personality conflicts within the practice, relationship conflicts outside of the practice, academic career cycle issues, changing skill sets, and retirement.
CHANGING WORKPLACE ENVIRONMENT
Until the mid 1980s, the demands and expectations of medical practice were predictable, well-known, and relatively stable over time. This paradigm of stability was replaced in the 1990s by one of constant change. Drivers of the health care industry now include physician and nonphysician managers, mergers and acquisitions, globalization or regionalization of care, increased competition, total quality management techniques, and for-profit managed care. Implicit for physicians in all of these factors is loss of control, change, increased attention to the financial bottom line, and unpredictability. Without a strategy to accept and manage change, many physicians are doomed to increasing stress, fear, and resentment. As mentioned previously, “geographic solutions” to those issues—that is, relocating practice to an area where managed care has penetrated less deeply—will not a satisfactory long-term individual solution.
PERSONALITY CONFLICTS WITHIN THE PRACTICE SETTING
Traditionally, the American Physician has been fiercely independent and self-reliant. Although these qualities and others have served physicians well, they also act as the seeds of interpersonal conflict within physician groups and organizations. Battles for control and leadership, gender issues, financial decisions, work habits, and professional “turf” issues are common sources of interpersonal conflict in physician organizations. In addition, financial and workload issues are becoming more common as reimbursement falls. Differences in patient-management decisions are less common sources of conflict.
THE “PACK” MENTALITY A factor affecting interpersonal dynamics in physician groups is the pronounced incidence of what can be described as a “pack” mentality pattern of behavior. With this scenario, the most aggressive or hostile physician in the group will assume a leadership and decision-making role at the expense of the less vocal, more passive members. Attempts to create intimate dialogue between physicians in this setting often leads to derision or personal attack instead. Physician groups function best when all members can openly speak their opinions without fear of derision, and in which all physicians have an equal voice. Problems are more likely to occur in groups in where there are inherent inequalities in decision making, voting, work time, patient load, income, or benefits.
GENDER ISSUES Gender issues also may become the source of interpersonal conflict. The proportion of female physicians in the work force is growing. Female physicians typically experience conflict around scheduling work time and time off to accommodate family needs and leaves for pregnancy. They are more likely than male physicians to seek part-time, flexible work hours; and the male medical community traditionally has been less supportive of such desires than many other professionals. The extent to which these issues persist today has not been studied systematically, although pregnancy leave-of-absence rules enacted in recent years in many states have had a positive impact in this area. As the proportion of female physicians and the growth of women physcians’ organizations rapidly increase, concern regarding these issues should decrease over time.
TURF BATTLES Professional turf battles have increased as sources of interpersonal conflict in medicine, largely among specialties. As reimbursement falls, the frequency and intensity of these conflicts increase as physicians try to sustain practice income through diversification of clinical procedures. Cross-training of procedural skills between two or more specialties is occurring in many residency programs. These conflicts are likely to increase significantly.
WORK HABITS Work habits are becoming a more common source of interphysician conflict. As professional dissatisfaction grows, an increasing number of physicians are seeking novel solutions, such as part-time practice, flexible hours, sabbaticals, and no night call. Those fortunate to be able to sustain reduction in income by working less than full-time may experience the resentment of others less lucky. There is still a strong workaholic ethic within the profession that takes a dim view of part-time medical practice. Despite this attitude, the use of locum tenens physicians, increasingly more common as physicians strive to find ways to reduce their clinical practice stress.
RELATIONSHIP CONFLICTS OUTSIDE THE PRACTICE
Physicians’ marriages fail at a significantly higher rate when compared to rates for the rest of the general population. In light of the stresses placed upon physicians’ spouses by the long hours, fatigue, and emotional exhaustion, it is surprising that this rate of divorce is not even higher. Many physicians’ marriages are sustained marriages of convenience for both spouses, although it is difficult to know how common this is.
Because of their work ethic, overdeveloped sense of responsibility and dedication, physicians typically place their clinical practice demands at the top of their list of time priorities. Therefore, given a choice between work and family, they will almost always choose work first. This choice commonly places an unusual degree of responsibility on the other spouse for child rearing, home maintenance, and planning the couple’s social calendar. Over time, many spouses grow to resent the imbalance in the relationship. Left unattended, these resentments are often the first seeds of marital discontent leading to divorce.
Unmarried physicians face equally difficult challenges of maintaining a meaningful social, sexual, and recreational life outside the context of their busy medical practice. This requires unusual energy, creativity, and persistence.
Faced with the emotional, physical, and intellectual challenges of patient care, many physicians return home at the end of the day exhausted and either unable to sustain or uninterested in emotional intimacy with their family, spouse, or companion. Renewing the marriage must become a conscious task and a priority if it is to mature and flourish.
Divorce is less common than malpractice as a cause for practice relocation and transition. There is less stigma attached to divorce on the part of the physician, and child-rearing responsibilities usually motivate the divorced physician to remain in or near the community of the pre-divorce years.
ACADEMIC CAREER CYCLE ISSUES
Physicians in academic practice may experience any and all of the traditional causes of professional practice transition mentioned thus e of far. In addition, the nature of academic practice introduces additional factors that may continue to a physician’s decision for career change. These factors may include problems with academic promotion/tenure, skill-reward mismatches relating to clinical care versus research, the politics of academia, and pressures relating to academic productivity and research funding.
Academic promotion and tenure are sources of career dissatisfaction that commonly result in job transition in academic medicine. Institutions in which basic research by faculty is highly valued to create intense pressure on junior faculty to establish research base, obtain outside sources of funding, and publish results to obtain promotion to tenure. Junior faculty commonly are also expected to teach, oversee the clinical care of patients, and demonstrate excellence in research as well. Few physicians are skilled at all three of these, and within this fact lie the seeds of dissatisfaction for many young academic physicians. Failure to obtain research funding, perceived lack of financial or political support within the department, or competition for declining numbers of tenured positions within academic departments leads many junior faculty to seek greener pastures at other academic institutions voluntarily. For others, failure to be promoted to tenure may obligate them to seek employment elsewhere.
Skill-reward mismatches occur in the academic sector of medicine also. Not uncommonly, faculty physicians—especially junior faculty—come to realize that their own skills and interests lie more in clinical medicine and direct patient care than in teaching and/or basic research. Occasionally the converse is true. Because it is natural to gravitate to those activities that showcase our job skills best, physicians experiencing such career conflict eventually must face the reality of their situation. They either fail to get promoted, or voluntarily find a position that rewards them financially with academic promotion for the skills that they most want to use.
CHANGING SKILL SETS
As physicians’ careers evolve and mature, certain clinical or management skills often become weaker or less important. Some may find that practice management is a better fit with their interests, skills, and temperament than is clinical practice. Others may lose clinical skills owing to changing patient demographics, resulting in less frequent use of certain procedures.
Physicians may lose interest in using special skills or in evaluating patients with certain specific problems that they perceive are more stressful or less challenging than is preferred. Older physicians may elect to stop performing certain high-risk interventions or surgical procedures. Other factors such as a desire to take less night or emergency call may play a role.
To the extent to which a physician’s desires to stop providing certain services to patients are acceptable to the institution or medical group involved, there is no problem. However, when those desires are not acceptable to partners, groups, or institutions the dilemma may not be resolvable by negotiation and may result in the physician leaving the practice setting to find a more compatible practice environment.
When physicians retire from the practice of medicine, they go through a natural transition process that is highly variable and individually defined. Full and complete retirement removes them from the rich professional environment that they have enjoyed and served in comfortably for many years. This transition to retirement living may not go smoothly, particularly if physicians have no well-developed interests outside of medicine, or if their financial picture or physical health is not stable. A life plan for retirement, derived with the help of a financial planner and a career professional, will go a long way toward easing the retirement transition. Aside from needing a plan that meets the financial needs of the physician and family, the retired physician needs a life plan that provides ample opportunities to find meaning, a sense of contribution, challenge, and fun. (A discussion of the details of such planning is provided in Chapter 3, “Financial Planning to Ease Your Exit.”)
PRACTICING PART-TIME Increasing numbers of physicians are choosing full retirement earlier than they had planned or are electing to phase back from full-to part-time practice. In most instances, these decisions are reached in an effort to deal with practice stress and burnout. Practicing medicine part-time is always complex, often requiring extended negotiations with practice partners and medical groups. The latter often fear that part-time physicians will not be as committed to the business and administrative side of running a practice as full-time partners. There are issues to resolve regarding the allocation of patients, night call, salary, vacation and time off, and retirement benefits. These issues need to be considered seriously and responded to by the physician who desires part-time practice. Downsizing a medical practice obviously has a major impact on personal and family finances and long-term financial plans and commitments. These issues are best worked through with the assistance of a certified financial planner.
Major changes in the milieu of medical practice occurring in the past decade have had a major negative impact on the mood and attitude of practicing physicians. Managed care has led to a loss of autonomy and control of patient care, increased work pace, and falling reimbursement. Growing dissatisfaction, frustration, stress, and burnout have resulted in increasing physician disability claims, rising malpractice litigation, early retirement, transitions away from patient care, and medical practice divorces. The emotional profile of physicians often interferes with their ability to manage these stresses effectively. Doctors’ training and work habits typically do not provide adequate coping skills or an appreciation of or ability to achieve life balance. Other practice factors that may contribute to dissatisfaction, transitions, and practice divorce include physical and behavioral disabilities, medical malpractice stress, skill/reward mismatches, mismatches of expected and actual workloads, personality conflicts between physician associates, gender conflicts, turf battles, and work style conflicts. Factors external to the practice that may drive a desire for transition include failed marriages and other personal relationships; changing physician skill sets and interests; academic career cycle issues; and conventional retirement.
An understanding of modern career cycle theory permits physicians to escape outdated mental and to acquire the skills needed to move away from feelings of victimization, fear, and helplessness in response to their career dissatisfaction.