Pros and Cons of Small Practices and Large Health Systems

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Physicians are faced with an important decision to make in their careers: where and in what type of setting will they work? Fresh out of a long cycle of education, the array and diversity of opportunities can be daunting to choose between. There are many kinds of healthcare settings, with various sizes, networks, and styles of care. For now, we will work with two major settings. Prospective physicians will find that the majority of employment options can be boiled down to two major settings – small, independent practices (SIPs) and large allied health systems (usually hospital settings, sometimes with site clinics). What makes one better than the other? For many, this is a decision based on priorities and values. Here is a list of pros and cons that can help you come to a more informed decision.

Small, Independent Practices

While the overall trend in American medicinal practice favors consolidation of small practices into larger health systems, SIPs continue to play an important role and function in the healthcare sector. Over half of medical providers continue to care for patients in settings of five or fewer colleagues. Clearly, there is something to be said for smaller practices. What makes physicians choose to work in a smaller setting, and what are the drawbacks?

Pros:

The most common reason that a physician might choose to work at a small practice is based on the quality of the work being done. Physicians working in a small, clinical setting have far more autonomy over their jobs, and this has proven to increase physician satisfaction. A study conducted found that while the national average of physicians feeling ‘burnt out’ was over 50% in 2014, the same study found that among over 150 SIPs the percentage of physicians feeling burnt out was only 13.5%. Physicians agree that this number is low because at small practices, doctors have more say in patient care and in setting their own hours. Working in a small practice affords you more time to develop quality relationships with patients in a more consistent setting.

A second leading factor that leads many physicians to SIPs is its emphasis on community. With roughly 29% of physicians being born in a country other than the USA, it is no surprise that many physicians gravitate toward smaller healthcare settings geared toward working with members of their own communities. Most immigrant physicians are also multilingual, and this creates a special bond between smaller healthcare facilities and the community. If you are looking to do lots of direct engagement and advocacy with your local community, then an SIP might be right for you. SIPs help cater their services to the needs of the members of their community, and this also helps create a strong, consistent patient base.

A smaller healthcare facility also offers a degree of routine that many physicians find important. With more autonomy over the kind of services provided, physicians have their days a little more under control than they might have at a large health system facility. Depending on where you are and what your lifestyle is, this may be ideal. 

Cons:

While the allure of a small, independent practice might be enticing, there are other factors to consider. Because of their size, these clinics often require physicians to do a great deal of administrative work. This might include scheduling and managing patients, working with billing, and managing and ordering medical supplies. Being a physician at an SIP requires wearing many hats, and for some, this work can be unfulfilling. In addition to administrative tasks, SIP physicians have more to do to ensure patient data safety. While larger health systems outsource this to electronic management services, at small, independent facilities, doctors on site help to manage electronic records.

While the routine nature of care and more stable hours puts SIPs in the favorable column for many, this same scheduling pattern may prove unsatisfying for others. Many physicians at SIPs move into larger hospital jobs as a result of the monotony they may experience at smaller clinics. While the work may be routine, for some it may also be boring. The prospective physician must consider their priorities to determine what balance of routine and spontaneity they want in their days.

Perhaps the biggest negative of working at a small, independent practice is compensation. Salaries may tend to be lower at small, independent practices than at larger hospital systems. More overhead costs, less efficient service provision, and difficult independent insurance contracts all contribute to the hefty financial burden SIPs face. However, there may be more room for salary negotiations at an SIP than in a larger system.

Large Allied Health Systems

The consolidation of smaller, independent practices into larger healthcare networks is increasingly rapid in 2020. There are many reasons for this shift. First and foremost, consolidation into larger health systems helps enable those systems to eat up a larger share of the market profit, bringing more money into the pocket of providers. Larger systems also help streamline processes, and operating costs may be lowered when operating on a larger scale. 

Pros:

Physicians employed by larger health systems may be more likely to have a higher starting salary than their SIP-employed peers. While some private practices may offer the opportunity for higher compensation due to ancillary services, in practice the average hospital-employed physician continues to out-earn the SIP-employed physician. Compensation opportunities are increased by hospitals’ ability to offer overtime. While a smaller practice may have more stable hours, hospitals operate 24/7, and so offer more available billing hours to their providers. 

In addition to compensation, large allied health systems offer job security that small, independent practices cannot. As costs ramp up, independent providers face an increasing set of financial burdens that often force clinic closures. Large, allied health systems operate all over the nation, with similar work opportunities available in most locations. With the trend toward consolidation of smaller practices, physicians may find less worry working for a larger health system.

Many physicians may also find that a large health system may provide opportunities that smaller practices do not. As employees in a larger system, physicians will deal far less with the administrative tasks often required of them at SIPs. This enables the physician to spend more time to dedicate to further specialization, cooperation with senior physicians, and professional development. If you are looking for a fast-paced, challenging work environment, then a larger health system might be right for you.

Cons:

Along with the benefits of a consolidated system come several drawbacks that you may want to consider as you choose where you want to work. Being a small fish in a big sea means that physicians’ voices are often ignored in favor of company higher-ups. A survey conducted by Medscape in 2016 found that 42% of physicians employed in larger systems disagreed with employers when it came to patient care philosophies, and 57% disagreed with some policies in the workplace. Larger bureaucracies make undesirable policies much more difficult to change. With a higher number of patients seen each day, the large health system physician may find themselves overwhelmed by efforts to increase productivity and may feel their voice go unheard. 

And while the fast-paced nature of larger health system settings may attract some, they also create more gruelling schedules. Physicians at large health systems and large hospitals work more hours than their SIP peers and more odd hours. Schedules are often inconsistent and require being away from home on holidays, or for many days in a row. While physicians often have a degree of control over their scheduling, there are still inevitable inconveniences that make a consistent work routine impossible, including being required to shift between days, nights, and extra shifts. 

The Bottom Line

Where you work depends on what kind of work you want to do. Think about the kind of work environment that might work best for you. Are you interested in a consistent schedule, or do you prefer spontaneity and change? Would administrative work provide you with a feeling of autonomy or feel like a burden? Do you prefer working in smaller settings, or is a larger hospital more suitable? How important to you is the kind of leadership and strong workplace culture that a smaller practice can provide? The answers to all of these questions will help determine what setting you may choose to work in. The good news: there is a wealth of opportunity in both settings, and with a growing healthcare industry, there’s sure to be a right fit for you.

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