Journal of Medicine - Victoria Rentel, a family physician in Columbus, Ohio, joined a hospital-owned group several years ago. At first, nearly everything went fine. There were a few glitches: she'd occasionally order tests or consults at competing facilities, either for patient convenience or because of health plan coverage. When the hospital's administrators found out, they told her it was a violation of her contract; but that didn't stop her because she knew the hospital never enforced this provision.

Four years after Rentel took the job, the administration praised her financial performance and promised to expand her solo practice by bringing in more physicians and adding more office space.

Then, out of the blue, she was informed that the hospital was going to close her practice within 45 days. She knew this wasn't her fault; the recession had hit the hospital hard, and it was laying off nearly half of the primary care doctors in her group. Still, it was a hard pill to swallow.

Making matters worse, her contract's noncompete clause prohibited her from going to work for any of the other healthcare systems in town. To avoid legal sanctions, she joined the student health service at Ohio State University.

Would she ever work for a hospital again? "I never say 'never' anymore. But if I did, I'd go into it with my eyes wide open and with much more due diligence than I did before."

Many other physicians -- especially those who, like Rentel, were previously in private practice -- complain about their jobs. In some cases, it's because physicians rushed into the arms of a hospital without looking carefully at their contracts or asking the right questions during their job interviews.

Older doctors are as apt to make this mistake as young ones, physician recruiters say. But doctors fresh out of residency expect to work for a hospital or a medical group, so they're less likely to complain about working conditions or compensation, notes Gary Matthews, a healthcare management consultant in Atlanta.

Ultimately, the loss of control over their own professional lives is what irks employed doctors the most if they used to be in private practice. But some doctors also get the sinking feeling that they've become cogs in the corporate machine.

"The reality is that when you work for a hospital system, you're a service line," says Rentel. "And because primary care reimbursement is relatively low, you're a service line that feeds more lucrative service lines."

1. Lack of Job Security

According to Matthews, some hospitals hire too many doctors, placing those physicians' incomes at risk.

2. Changes in Compensation

Employers may unexpectedly change the requirements for earning payment.

Additionally, some physicians who are thinking about leaving a hospital's employment don't believe they get paid enough, notes Jim Robbins, Vice President of Delta Physician Placement.

Robbins has seen situations in which the hospital bumps up production goals without paying doctors more. "If family physicians have an employment agreement without any kind of production bonus, they're going to increase their patient load by 10 or 15 people a day, and they're still going to be paid the same."

Because of physician shortages and hospitals' eagerness to employ doctors, newly hired doctors may receive higher salaries than those who have been in a hospital group for a while, Robbins adds. That will irritate the doctors who have been there longer and get paid less.

3. Call Schedule is too Burdensome

Some physicians are unhappy with hospital call duty, Robbins says, especially if they're primary care doctors who are used to handing off their patients to hospitalists. But a high percentage of hospitals now have hospitalist programs, even in rural areas, notes Matthews.

Newly hired doctors may also resent having to take call more often than senior colleagues do, Robbins observes. This may happen if a hospital or physician group has bylaws stating that after a doctor reaches a certain age or length of tenure with the group, their call duty will lessen.

A Delta survey of primary care doctors indicates the gap between their call duty preferences and what their jobs actually entail. A total of 57% preferred no call with a hospitalist program; 40% preferred call that was separately compensated; and 3% had no problem with uncompensated call. But in their current work environment, 28% had no call with a hospitalist program; just fewer than 20% had compensated call, and 52% had to take call without pay.

4. Lack of Business Control

A doctor coming out of private practice is used to running his or her own office. It's a big shock to some physicians when they discover that the hospital has taken control of all their business functions. In many hospital-owned practices, Robbins says, the hospital controls everything from "how the phones are answered to the signs on the doors to compensation. Maybe your x-ray tech is now under the direction of the chief radiology technician of the hospital, instead of the physician."

Another area where doctors may lose income, he adds, is in ancillary revenues, which typically form a third of primary care doctors' volume. "When a hospital acquires a practice, those ancillaries are swept up into the hospital, and they're not figured as part of the practice revenues."

5. Lack of Clinical Autonomy

As hospitals and medical groups alike put more emphasis on quality improvement and measurement, many employed physicians feel like they're losing their clinical autonomy. And the problem is compounded if quality scores determine a significant part of their compensation, according to Robbins.

"That's part of the loss of autonomy that bothers doctors even more than the business side. Most of them hate it. They say, 'I do a good job, I take good care of my patients.' Now they've got to meet certain metrics. And often, those metrics are part of their compensation plan."

6. The Tyranny of Noncompete Clauses

Employed doctors intensely dislike noncompete clauses, which they view as an unfair constraint on their potential mobility.

In Texas, Robbins is seeing an increasing emphasis on noncompetes in employment contracts. "The majority of contracts that have those clauses are reasonable. They might say you can't set up practice within a 10-mile radius or 30-mile radius of the facility. The problem I see sometimes is that you may have a corporate affiliate with 8 hospitals in 7 counties, and you can't compete close to any of them. That's unfair. But there are laws and regulations against that."
 
Noncompetes can sometimes discourage doctors from changing jobs. For example, if you have a noncompete with a 30-mile radius in Dallas, adds Robbins, "you probably can't work in that market if you leave your hospital. So that might prevent a doctor from leaving."

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