July 18, 2024

By Steven Furr, M.D., FAAFP
AAFP President

Americans celebrated their freedoms and independence earlier this month, but many U.S. physicians say they feel a lack of both. 

A Becker’s article published in late June shared results from a Physicians Foundation survey that offered five key reasons physicians are leaving medicine:  

• loss of autonomy,
• declining reimbursement,  
• increased consolidation, 
• burnout  and 
• educational costs. 

Those five points are connected in many ways. Loss of autonomy can fuel burnout, as can concerns about payment and debt. (A recent AMA survey shows physician burnout rates are improving, but maintaining that trend will depend on the type of advocacy work being done by the AAFP.) 

I’ve been a practice owner since completing my training in the 1980s. I choose how I practice, where I practice and who I practice with. It’s been so rewarding that I have no plans to retire, though I recently turned 70.  

Unfortunately, it’s a different world now for practice owners with higher upfront costs and greater regulatory and nonclinical burdens. Many of my peers have retired or joined the ranks of the employed, and the majority of young physicians, left with fewer choices than ever because of vertical integration and medical student debt, are taking employed positions straight out of residency. In fact, 91% of the AAFP’s new physician members were employed in 2023. 

Although practice owners earn more than 15% more, on average, than our employed peers, the trend is clear. From 2011 to 2023, the percentage of employed AAFP active members rose from 59% to 76%. Although that option will work out for many, I fear that with that trend we’re losing autonomy and the freedom to practice medicine the way we want.  

From 2019 to 2021, more than 108,700 U.S. physicians left private practice for employed positions. Some of the advantages of such a move are obvious, starting with a stable, predictable income without the stress of running a small business. 

But I wonder about the tradeoffs. What have practice sellers given up? Someone likely is telling them how many patients they must see, and possibly limiting their scope as well.  

So, what do we do about that troubling list that Becker’s provided? 

The Academy has supported the FTC’s move to ban noncompete agreements, which would apply to many employed physicians. That rule has been enjoined, pending a legal fight we were expecting. It remains to be seen how that battle will play out, especially in the wake of a much broader ruling by the Supreme Court.

Meanwhile, we need to ensure that students, residents and physicians have a high awareness of noncompete clauses, which can make physicians feel trapped.  

What’s worse than a bad situation?  

Having no control to change it without leaving our patients and communities behind. 

The AAFP has resources that can help us review contracts (with an attorney), spot red flags and negotiate better terms.  

The Academy also has resources to help physicians considering direct primary care, which now accounts for roughly 9% of the family medicine workforce. It’s worth noting that as DPC grows, there will be opportunities to benefit from being an employed physician in that setting without some of the headaches our peers in large health systems face. 

There are other practice models to consider, and that’s a message students need to hear before they make a binding employment agreement. Family medicine training gives us the flexibility to practice inpatient and outpatient care; we are needed in urgent cares and emergency rooms and everywhere from labor and delivery to nursing homes and hospice care.  

Why should our next generation give any of that up before they understand all their options? If you work with students, I hope you'll encourage them to seek electives in physician-owned practices so they can see the difference in scope and settings. (One thing that may stand out to them is that, according to the AAFP’s Compensation and Career Satisfaction Benchmark Dashboard, the average full-time compensation for family physicians in independent practice is $297,015.)

I was a community preceptor before I joined the AAFP Board of Directors, and I hope to resume that important role when my term ends. If you love what you’re doing and are passionate about family medicine, please consider showing students and residents what you do, regardless of your practice setting. 

Oh, and what about reimbursement?  

The AAFP is continually advocating for greater investment in primary care, and I’m optimistic that the Medicare G2211 add-on code will mean more income for family physicians. 

But how do reimbursement and autonomy fit together?  

Although I’m a practice owner, I’ve always had other sources of income. I’m an attending physician and medical director at the local nursing home. I also work with attorneys across the state as an expert witness in malpractice cases. 

Years ago, I was medical director for a home health agency. I repeatedly raised questions about an aspect of the business I didn’t agree with. Rather than change its methods, the business decided to change medical directors. I left, gladly, and I had the flexibility and autonomy to do so. 

Independence is a great thing we should celebrate. We also should encourage our students and residents to experience it.