How to Kill a Medical Practice


Have you ever watched a pee-wee soccer (football, for the rest of the world) match?  One mass of munchkins chases the ball around the field, shifting direction as the ball pings from one side of the field to the other.  There’s no semblance of actual positions, with the exception of lonely goalies at either end of the field, forlornly picking daisies or their noses.  That blob of kids reactively chasing an elusive orb is a reasonable metaphor for my organization’s Administration.

A couple of years ago, my group transitioned from a several-year period of chronic financial stress to acute decompensation.  It was ugly.  Admin adopted the most directive posture any of us had ever seen, issuing edict after edict, designed to plug the ever-widening cracks in the dike.  Unfortunately, because clinical and support departments were already extraordinarily lean, the only lever Admin could pull was the one that kicked doctors in the ass to work harder.  Hours expanded to nights and weekends.  Time allotted for certain visit types was decreased.  Departments were required to increase the percentage of providers in the office on any given day from 50% to 70%, making it harder to take contractually-provided time off.  Any day of work missed due to illness would now count as a vacation day.  Morale tumbled into the toilet, yet Admin continued to chase the ball (financial performance), with little regard for the fact that the grass on the field was withering and dying, the entire playing surface transforming into a tired patch of dirt.

Sadly, the referee’s whistle took a couple of years to signal the end of the half.  The blob has finally looked up, with the confused expression of a dog who’s just been yelled at for a transgression committed several hours ago.  The physicians and other providers in my group have been complaining for years that draconian policies and lack of appropriate resources have contributed to the immensely unsatisfying practice of medicine that is now our status quo.  Admin is just now starting to “get it,” but it may be too late.

The Exodus

Like the proverbial frog in a boiling pot, we’ve been losing healthcare providers in a steady stream, as they disembark for pastures that are – if not greener – slightly less brown.  My multi-specialty group now finds itself in the position of having so few primary care doctors remaining, that we are in danger of losing a number of patients that reaches well into five digits.  We simply can’t recruit new doctors fast enough, nor can we cross our arms and wiggle our noses to magically ramp the ones we hire up to full speed, maintenant.  Of course, we should have burned more ATP addressing the pain points of disgruntled docs with mature practices in order to retain them, as opposed to simply recruiting newbies who are too green to know how much they’re going to hate working at my group.

So here’s where we’re at: for two years, we cultivated a laser-like focus on the bottom line, to the exclusion of provider job satisfaction.  To Admin’s credit, this did put us in a better financial position – for a few seconds.  Now, however, we’re hemorrhaging primary care doctors, and the blood bank has declared a shortage of O-.  Translation: we’re screwed.  Assuming Admin doesn’t repeat this whole boondoggle when our profitability starts tanking again due to low visit numbers, it will still take years to rebuild what we’ve destroyed – if we can last that long without being sold off for parts.

Every day, patients complain to me that they’ve been through three primary care providers in the last 2-3 years, as they pontificate whether it’s time to seek care at a competing group.  While I understand that there are challenges at almost all medical organizations right now, it’s getting harder to make a convincing argument that patients should stay with us.  When they ask me who I’d recommend as their next PCP at our group, I don’t even recognize 80% of the names in the staff directory.  My patients are frustrated, as am I – my last two PCPs were at my group…and now they’re not.

The Loss of a Referral Base

In addition to losing office-visit revenue as primary care docs who cared for tens of thousands of patients leave, there are other problematic downstream effects.  Specialists like me depend on PCPs for referrals.  Over the last 3-6 months, my department has seen demand decrease.  For well over a decade, it took 4-6 weeks to get in to see one of us, even as the department expanded; now we typically can get patients in the same week or even the same day they call.  While I much prefer this degree of access for the purpose of delivering timely, efficient, high-quality care, demand this soft threatens the financial viability of my department.  I know of a couple other specialty departments that are also seeing softer demand; I suspect it’s only a matter of time until it’s obvious to all that the entire group must endure a painful contraction.

Recognizing the current state of affairs, you would think that Admin would be bending over backward to support the crew that hasn’t yet abandoned ship.  To their credit, they are trying really, really hard.  They are going on “listening tours” around the clinic.  Our inboxes are clogged with surveys on a regular basis.  They are walking back some of their most unpopular edicts.  But here’s the thing: without a drastic overhaul of the culture in our group, none of this is going to have the desired effect.

Culture is Key

The culture used to be amazing – that’s why I hired on in the first place.  If I had to distill its greatness down to the single most important concept, it would be this: every aspect of the organization was designed to help the doctor do her job.  It didn’t matter if the job was taking care of patients, charting, negotiating for new equipment, or supervising other doctors.  When that doctor walked into someone’s office with a problem or request – regardless of whether it was an accountant, coder, purchaser, CMO, COO, or CEO – that person’s first question was “What can I do to help make things better?”

That culture has morphed into something much less functional and infinitely more frustrating.  Granted, much of this is the product of exponential growth in a short amount of time, essentially outgrowing the original management structure and overwhelming the organization’s limited human resources.  But it’s more than that.  We’ve empowered people who never should have gotten anywhere near power.  These are people who do not ask “What can I do to help make things better for you?”  Rather, their initial reaction to any physician request is more along the lines of “I don’t know if we can do that…” and “How can I assert my authority in this situation?”

The Focus on Patient Satisfaction

In combination with endless obstructionism, the organization has also attempted to shift our focus from physician-centric to patient-centric.  On the surface, this sounds like a no-brainer, great idea.  Who could possibly argue with the concept that focusing on providing the best patient experience will bring great success to the group?  Happy patient = happy Admin = happy doctor, yes?  No!

The last several years have been spent forcing doctors to work hours they hate because “patients want it;” forcing the clinical teams to participate in ridiculous exercises purportedly designed to enhance patient satisfaction; and trying to improve in areas where we’ve been graded lower by patients, without the benefit of actionable guidance on how to move the needle.

Whether you believe it or not, most physicians I know practice medicine because they want to help people; our patients’ satisfaction with our care is extremely important.  But, when you look at everything that’s happened in my group these last few years, the focus on patient satisfaction has come at the expense of the focus on physician satisfaction.  The question is, can we do both?

Reconciling Patient Satisfaction with Physician Satisfaction

I believe that we can, but not in the way you might think.  I believe that most of the touchy-feely initiatives directed at enhancing patient satisfaction are worthless.  Let me be clear: patient satisfaction is critical.  The initiatives are worthless.  In the business world, it’s well-recognized that a company with happy employees who enjoy their jobs leads to satisfied customers.  In other words, when it’s clear to customers that the people who work at the company love the company, the customers are more likely to love the company, too.

Medicine should be no different.  Though it may seem counterintuitive, in order to make our patients happy, we need to stop trying to make our patients happy.  Stop pushing work hours that prevent physicians from enjoying time with their families.  Stop making it difficult to take time off for medical conferences or vacation.  Stop penalizing physicians for the human fallibility of occasional illness.  Stop shrinking our appointment lengths and treating us like revenue-generating widgets.  Start treating us like high-performing professionals.  Start removing people and other obstacles that prevent us from efficiently doing our jobs.  Start being supportive of physicians who want to cut back their clinical time to extend their career longevity.

If Admin can do all this, we can make being a doctor great again.  I promise you that patients will love their happier, engaged, and more relaxed physicians.  We will come across as better listeners and more empathetic.  As an added bonus, we will increase retention of these satisfied physicians, which will further enhance patient satisfaction as patients develop years-long (instead of months-long) relationships with their doctors.

How to Kill a Medical Practice

On the flip side of the coin, if Admin chooses to focus on the money instead of the mission, our group will die.  If Admin continues to focus on what they think patients want, to the exclusion of what physicians need, our group will die.  If Admin fails to aggressively demonstrate through action (not just words) that a culture shift is our new top priority, our group will die.

You might ask, how does someone with a glass-half-empty-and-leaking viewpoint feel about our chances?  I’d say about 50-50, which is probably more generous than you would have surmised reading this piece.  My organization now has several people near the top who seem to “get it” and whom I respect tremendously.  The million-dollar question is: the next time the financial feces hits the fan, will they double down on the path I’ve laid out, or will they revert to the strong-arm strategies that brought us to this precipice?


If you’re a healthcare provider, what do you think are the most pressing pain points at your group?  Biggest challenges?  Areas with the most potential for improvement?  How would you fix the problems where you work?  Do you do patient satisfaction exercises?  Have any of them been helpful?  If you’re not a HCP, I’d love your perspective on all this, too.  Patient commenters on some of my other posts have eloquently explained how the medical system and their physicians have failed them.  Taking into account the information I’ve provided in this piece, how could your satisfaction with care be increased within the confines of the current system?  Do we need to blow the whole thing up and start over, or can you see a way forward where we could achieve both physician and patient satisfaction?  When was the last time you sat down with a relaxed, happy physician who seemed to be listening to you?  Comment below!

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Image Credit: Photo by Cristian Newman on Unsplash

12 Replies to “How to Kill a Medical Practice”

  1. I went through this same struggle for years as a co-owner of a multispecialty group. Eventually I left and started an affordable Direct Primary Care practice.

    While the transition is stressful, my DPC practice is a much better model for both patients and physicians. At this point, DPC is also less risky than basing your practice on insurances.

    1. Good for you, Brian! Glad it’s working out. If I was a PCP, I probably would have gone this way by now.

  2. You could be describing the fast-growing physicians’ group in my area — the one I do my utmost to avoid. It swallowed up the practice that grew out of a doctor who was paying back public health service financial support for medical support and recruited by a local organization formed for the purpose of bringing medical care to our rural area. The organization built an office. Over 30+ years the practice grew to 3 PCP’s and flirted with being affiliated with a large hospital system but backed out. The local ad hoc organization expanded the building. Then the original doctor who owned the practice died. His widow sold the practice to the fast-growing physicians’ group. They built a new office building closer to their home office next to the hospital. PCP’s retired. PCP turnover increased. The PCP’s had their time per patient monitored and restricted. We left and found one of the few remaining PCP’s who are not members of the fast-growing physicians’ group. Fortunately the kids are grown and on their own and managing their own care so having a doctor 15 minutes away is no longer important.

  3. I’m not an HCP, just a consumer of healthcare and, by and large, I’ve always been very satisfied, so there’s that. I’ve worked in small and large technology companies in my 30+ year career and experienced and watched similar stories from airline pilots, design engineers, phone companies, and system vendors (aka, OEMs).

    I don’t know if there is a solution. It’s highly understandable that shareholders demand financial results. Their priorities drive boards and management. Globalization means more competition with companies with lower costs and more draconian work ethics. And those companies are staffed by people who are starving for their own participation in their version of the American Dream.

    In some ways the larger US economy is following the experience of coal miners, steel workers, and the manufacturing industry. We have to stop playing the same old game and change/adapt. But nobody really knows how to do this.

    Perhaps for healthcare we should nationalize it, like in Canada, the UK, Sweden? It sounds idyllic from the outside but I’ve heard plenty of complaints. And regardless of whether you’re blue or red all of us are suspicious and untrusting of government bureaucracy.

    It’s a very tough problem. But problems are opportunities, right? I do certainly agree that it’s high time for management of all industries to get their heads out of their asses and think different. Look at what companies like Amazon, Virgin, and their ilk are trying, and start trying lots of things, see what sticks. The same old same old is, as you said, like trying to stem the tide with fingers in the dike.

    1. Yes, problems are opportunities. I am very interested to see what Amazon, JP Morgan Chase, and Berkshire Hathaway will come up with regarding innovation in the healthcare/insurance space. I feel like most of our current “solutions” are merely elaborate workarounds that cost us time and energy.

      1. I suggest reading “The Innovator’s Dilemma” by Prof. Clayton Christiansen of Harvard. He observes that established companies are so limited by their success, market positions, and financial performance, to truly innovate. Small companies or innovators such as Amazon, Google, and the like, have little to lose and much to gain by disrupting the big guys with “good enough” products and services that aren’t hindered by their status quo.

        The moral of the story: the only constant is change. Break out of your comfort zone and throw in with a group like Amazon. Medical services are a new gold rush! Even if the company or team that you join doesn’t rise to the top you’re participation and experience in the disruption will be marketable to others. You’ll be needed and in demand.

        1. I agree that the problems with healthcare provide a tremendous business opportunity for those who are brave/smart enough to turn the whole model on its head. If Amazon came knocking on my door, I would definitely be interested in hearing them out.

  4. “Let me be clear: patient satisfaction is critical. The initiatives are worthless.” Great point that happy doctors make for happy patients, but not vice-versa. I recently had a great interview with Victor Montori, author of Why We Revolt, and one of his main points is that th e medical lexicon has now become the same as banks and financial institutions. The way our administrative bosses talk, and the way they see things are no longer from a medical framework, but from a money framework. We cant improve patient care and doctor satisfaction until we fix the dialogue.

  5. Really enjoyed this, thank you. I’m one of those new s that inherited this mess. I went into hospital medicine instead of primary care for most of the reasons you laid out. For me, the daily grind of seeing 3 to 4 pts an hour would suck all the joy out of being a pediatrician.

    I really enjoyed clinic and the relationships I built over those three years as a resident. I wish things were different.

    1. Yeah, I hear you. Many of us went into medicine to enjoy these long-term relationships, but they are so hard to enjoy when cycling through 3-4 patients/hour. Shift work in the hospital gets you more flexibility with your schedule, at the expense of forming long-term relationships.

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