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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome to Health Fairs This Week. I'm your host Jeff Beyers. We're recording on 09/26/2025. Today, we welcome Yul Echness from Brown Health Medical Group who wrote a forefront article titled Deprofessionalization, an emerging threat to the physician workforce. This is as good as place as any to promote our second insider trend report that we released in July.
Jeff Byers:The report is titled The Healthcare Workforce, A Challenge in Sustainability. Check it out as it serves a nice foundation for what Yul and I will talk about. You'll also wanna get on the ground Floor as we are releasing our third insider report this year in October on private equity and its impact on health care. And now let's talk about deprofessionalization. Yul, welcome to the program.
Yul Ejnes:Oh, thanks a lot, Jeff.
Jeff Byers:Yeah. So you're a practicing physician. Generally, how can you frame the physician work experience for us? Yeah.
Yul Ejnes:I mean, days, a physician is very likely much more than ever to work in a large group of various ownership models, physician owned academic health centers, insurance companies, venture capital. And according to some of the surveys, up to 80% of physicians are employed and that number isn't going to be going down. And it's a contrast to the small physician owned practice that I started in decades ago in that today's physicians are going to have less control over their day to day work outside the exam room and then sometimes even in the exam room because non physicians are managing and making decisions on staffing, scheduling, contracting compensation in return for physicians being relieved of many of the headaches that the physician owner model had years ago. But, you know, as I argue in the article, I think in the trade off, there are some new headaches that physicians are having to deal with.
Jeff Byers:Yeah. So are these new headaches why you're retiring?
Yul Ejnes:No, actually, it's for personal reasons. I'm hitting the age where I want to leave before my parts start to break. I I think having experienced a lot of the change going from a two person practice in 1990 to where I am now in an academic health system owned practice, I think I've navigated the waters and I think I've worked through a lot of solutions to the problems I identify that I hope others will listen to and adapt to their organization since this is how it's going to be for physicians and we got to make it work.
Jeff Byers:Yeah, yeah, you outlined some of those anecdotes in the Forefront article and we'll make sure to talk about those today. I also encourage our readers to check out the actual article, as I'm sure we won't get into everything. But it's nice to know that, you you know, on your way out, can get some jabs in while also providing the perspective for us of, of the wisdom and and how you've navigated your career. So, just looking at what is de professionalization and how does it manifest itself as more physicians become employees? You noted that stat of eighty percent, physicians are becoming employees.
Jeff Byers:What's at risk there?
Yul Ejnes:Finding a definition is actually a hard thing to do. It's a term I came up with for about ten years ago after an experience I had in my day job and I didn't even know if it existed as a word but it turns out to be in the literature. I think of it as the loss of physicians' identities as members of a profession with its unique roles and responsibilities, expertise, and special relationships with their patients. And I also view it through two lenses. I mean, intrinsically how physicians feel about themselves as professionals.
Yul Ejnes:And then extrinsically is whether the employers view the physicians as professionals or just another group of employees. And I mean, think it's a result of how managerial practices get applied to a medical practice. Managerial practices may work in an airline or maybe a factory, but conflict with the needs and values of physicians, professionals.
Jeff Byers:Yeah. And I I wanna unpack that statement of what you just because, when you talk about deprofessionalization and about a certain loss that can come with a profession with that idea, you know, don't talk out of turn, but, like, I do kinda wonder, like, how has AMA you know, you know, they've been protecting physicians and as a professional class for a very, very long time, you know, as many of our listeners probably have sure have read the social transformation of American medicine, outlines that quite quite a bit. Any thoughts on that or, like, how they're like, with the increase of employers, how has AMA responded?
Yul Ejnes:Okay. I and I should I should give you a disclaimer. I'm actually, a member of the AMA House of Delegates, so I'm involved with AMA through representing the American College of Physicians. So I'm familiar with what they're doing in this area, and actually it's quite a bit. There's a whole collection of materials called AMA Steps Forward, And the focus has been really on physician burnout.
Yul Ejnes:This is not burnout but intersects with burnout quite a bit. So a lot of conversation about how to give physicians voice if they work in large organizations, how organizations can help preserve the professional part of what physicians do in terms of patient care and preserving the relationship. So actually in terms of tools and just raising awareness, in fact, I think they have a program that recognizes healthcare systems that do the right thing in terms of making their physicians feel like physicians. So yeah, that actually is quite maybe not as well known a set of resources, they've been talking about that for a few years.
Jeff Byers:Well, Thanks for taking that side quest with me. When you talk about the managerial aspect of it, which you bring up in the piece, you write about the risk of deprofessionalization is more related to the practice size rather than who owns it, which I thought was a very interesting comment. Can you unpack that statement a little bit more?
Yul Ejnes:Yeah. When a practice gets large enough, it actually takes on an identity of its own. It's the practice. So instead of being you know Doctor. Ejna's office it's now you know so and so clinic or such and such medical.
Yul Ejnes:And also as the practice gets larger it needs to hire professionals to do some of the work that a larger organization needs done, you know, human resources, IT, contracting. And with each iteration, the separation between the physicians on the front line and the people managing the practice increases. And eventually it ends up looking like some of the large organizations. It's an enterprise, you know, more than it is a small practice. And that's independent of who owns the thing.
Yul Ejnes:I mean, was involved in a practice that grew to a 100 plus clinicians, mostly physicians, owned by physicians. I owned 3% of it, but we had an organizational structure, management structure with, you know, office managers, directors, vice presidents, etc. Every bit as much as the large health system that we ended up joining a few years ago did and many other healthcare organizations do. So I mean, lot of this can go on even if the doc nominally is the owner and the organization is accountable to the physician owners or if it's owned by a not for profit venture capital, etc. I mean certainly when ownership changes, the mission and culture may change.
Yul Ejnes:So if you're driven to profit as opposed to service, that's going to shade this. But even in its purest form, we're there for the patients, the organization becomes an entity unto itself where its needs are often, met at the expense of the the needs of the professionals and the patients that they care for.
Jeff Byers:Yeah. So what's interesting, you you mentioned on our on our prep before we actually started recording that you're retiring, so which I which is why I bring this up. When you look at this and you look at the stat of that eighty percent of physicians are employed and you don't think that's gonna go down, you know, I can't tell the future, but I would expect that that it won't go down as much either. So, like, for a physician coming into practice or just out of residency beginning to practice, like, you know, it might be you know, change is scary for a lot of people, present company included. Like, what might you tell a young physician about to go through this or, like, how you might recommend that they navigate the waters of, like, either owning their own practice or being employed and and changes of ownership, you know, as specific like, a life's lifespan became something else recently.
Jeff Byers:You know?
Yul Ejnes:Yeah. I I mean, I I think, and this is actually, was one of the antidotes I I listed in the article is learning how organizations work and how to advocate for yourself and your patients within your own organization. I mean, I've been involved in professional societies for most of my career, the American College of Physicians primarily, and we spend a lot of time talking to young physicians, residents, students about how to advocate for your patients with a legislator, with a regulator, with insurance companies, but maybe not so much with the person who signs your paycheck, your employer. Understanding the, ecosystem of a large organization, I refer to something called the Abilene Paradox, and, you know, basically, is ready to go and change something, and they go to a meeting and they walk out doing the opposite. And it's, you know, the the issue of personal loyalties, people not wanting to have a ding on their review for not being a team player, being shy, etc.
Yul Ejnes:And just understanding that ecosystem to you know not mitigate all the frustration but at least understand why things happen the way they do. And then maybe learning how to, you know, have agency in that type of structure. Certainly there's still some niches where a small practice will continue and be an option. Direct primary care, for example, is one. Concierge medicine, which is another.
Yul Ejnes:But one can always leave a job if they don't like the conditions of their current job, but is the grass always greener on the other side if, you know, most of us are employed and you're going from one employer to another? So there's an irony in that, you know, you can leave if you want, which is the non compete clause, which getting back to my premise that physicians are treated as just another bunch of employees except when they want to leave, in which case now they're a valuable asset that may not be able to practice across the street. But, you know, those are the realities and I know there's a lot of conversation now about getting rid of non compete clauses and physician employment contracts. But, there's ways of living in the system as it exists and will exist. I think there's just got to be a lot of learning and I think that should start in the medical school and residency level and the organizations mentoring young physicians to show them how to navigate, how to be able to, you know, be there for your patients and for your professional identity even if you're in a, you know, large organization that's got metrics and policies and procedures and all those other things that we just love.
Jeff Byers:Yeah. Yeah. The administrative state. Is there anything from, like, a a a personal level that you would you would recommend them? You know, my sense as a nonphysician, and you can correct me if I'm wrong, is that, you know, physicians like to be in control.
Jeff Byers:Like, to take directives from a manager or from an organization within an enterprise. Is there anything that you could touch on with that?
Yul Ejnes:Yeah. I mean, you know, the issue of autonomy comes up and the loss of autonomy. I'll tell you, having gone from a two person practice to a three to a 17, etcetera, etcetera, with each change, you lose some autonomy. I mean, if you're all by yourself, you can decide everything. When you have a partner, you have to compromise on things.
Yul Ejnes:So that's not specific to the employment model of practice. Think where physicians don't want to be told what to do is what happens in the exam room. And it's not just the employer. I mean, it's insurance company, prior authorization, all those wonderful things. In terms of things that, you know, have to do with how a large organization operates as opposed to a privately owned company, then, yeah, you'll take direction.
Yul Ejnes:I mean, HR picks the insurance plan for employees. There may be rules for how you hire people and physicians, I would think in general, that as something they're not going to be driving the car on because they're employees. I would say though a lot of these directives that are part of being an employee, physicians tend to be inquisitive by their nature. I mean, they have to be. They don't accept things at face value because sometimes, you know, the diagnosis the patient came in with isn't correct.
Yul Ejnes:So I think again in contrast to how you might treat the cashier at the cafeteria or someone who's doing housekeeping, physicians I think like to know the why and if it doesn't make sense to them they want to have you know conversation about why it doesn't and see maybe things can change. I mean I talk often with my colleagues about the tyranny of the three C's, which is compliance coding and computing, where things don't seem to work and when the question is asked, why are we doing it this way? The answer is, well, compliance said we had to do it, or this is what the coder said. And and and these are all very valuable members of of the team. I don't wanna start getting hate mail from the CIOs and so on.
Yul Ejnes:But they give advice, and sometimes the advice is an interpretation that others may differ on, or it may be something that is in a perfect world, but in the real world where we're dealing with patients, we may need to do something different so that people want to have something more than because we said so when they're following direction. I mean, it's not realistic to assume that every physician is going to do everything the way they want in an organization of hundreds of clinicians and thousands of employees, but, you know, understanding how physicians work, where things matter from a clinical perspective, which may not seem on the surface if you're looking at things like scheduling and the call center, that seems like a managerial issue, but it's very much a clinical issue because it affects how the patient workflow works with the doctor, how much time the doctor has with the patient, and there needs to be a conversation and give and take in those areas, even identifying which areas that seem managerial are in fact in that gray area between clinical and managerial.
Jeff Byers:Well, we teased out some of the antidotes already for de For the listener, can you explain what those are? You know, you don't have to repeat yourself if you know, for for the ones that we have talked about.
Yul Ejnes:One one theme that that came up as I thought about this, is is physician self governance in areas where it's appropriate, and it actually aligns with the needs of the organization. An example that I raised in the paper that got a little more coverage in a JAMA viewpoint article several weeks ago is the organized medical staff, which was a model that was created, I think, the beginning of the 1900s when physicians took care of patients in hospitals. And the organization was set up where the medical staff dealt with the clinical matters, the administration dealt with the heating, plumbing, cleaning, etc. And then where you know things were cross cutting, they had the medical staff executive committee that you know worked things out. And in the current environment where doctors aren't going to hospitals I don't go to a hospital anymore but the issues of the divide between clinical and non clinical is still there.
Yul Ejnes:You know looking at a similar model, in fact perhaps that's what unionization is trying to create, you know, model where the physicians have a vehicle to express their needs and communicate with management, having it built in. The antidote that I listed was putting physicians in decision making places that are not just related to pure clinical. So for example, I always like to harp on scheduling and and the call center is, you know, wouldn't it be nice if a physician had veto power over something that just made no sense at all? That might have made sense from, looking at what works at Amazon or some call center, but not in the doctor's office. We have a lot of physicians in management, but they're managers with medical degrees as opposed to physicians with decision making authority who can, you know, speak to the experiences of the physicians and the needs they have in order to take better care of their patients.
Jeff Byers:In the questions I sent you, I felt there was a little bit of a paradox of wanting less administrative work, but also wanting to be informed and involved with decision making, which generally involves administration and information intake. Like, what is the thread there from your end?
Yul Ejnes:Yeah. Mean, I don't think it's either or. I mean, let's you know, think about this. If we do this right, the organization benefits greatly. Happier doctors take better care of patients, which is what the organization presumably wants.
Yul Ejnes:There's less turnover, and turnover is super expensive for an organization in terms of loss productivity, which is another P word I don't like in addition to provider. But you know, so it's a win win and the issue isn't necessarily giving physicians control over things that they shouldn't have control over because they're employees, but, you know, having the dialogue, understanding why certain things I mean, again, back to the call center. I mean, to administration, abandonment rate, on hold time, call volume is they're the kings. Those are the things that you reward your your call center on. From my perspective, it's did the patient get booked, at the right time in the right place with the right person?
Yul Ejnes:And they're not, you know, at cross purposes to one another. It's just a different type of language and dialogue and maybe not so easy to measure. But, you know, I'm not saying physicians should be organizing call centers, picking the software, you know picking the insurance plan with HR, but the things that affect what goes on in the exam room, even if at first blush they don't seem to be relevant and in fact are, I think docs should at least have a say in a vehicle so that they don't get everything that they want but at least what they get is heard. Mean you know one of the expressions of frustration that I hear sometimes which breaks my heart is from a doctor, you know, who's gone through all the training and has some experience in practices, I'm just an employee. I mean, how sad is that?
Yul Ejnes:And, I mean, it's gotta be sad to the person saying it, and it sure hurts a colleague. I I think we need to, structure the organizations in ways that that doesn't happen. You may not like what decisions are made, but at least you feel that you're still a doctor and not just an employee.
Jeff Byers:So doctor Edgness, before we wrap up, again, listeners, check out the forefront article. Is there anything that we haven't gone over that you just like to make sure that we touch on today?
Yul Ejnes:Yeah. Back to the antidotes, another one that I think we really need to take a look at, and it's a conflict between the managerial way and our way, is this fixation on centralizing and standardizing everything, which is, you know, it makes sense, you know, if you're making quarter inch bolts or if you're, you know, flying a fleet of seven thirty sevens to standardize and centralize. But the one size fits all doesn't work for everyone. It works for some things, but not but, you know, the the conversation often becomes, we need to do x, y, and z differently so we can standardize and centralize when it should be the other way around saying, you know, we're we're gonna try to standardize and centralize so we can do x, y, and z better. And and, again, this is an area where the physicians, the professionals can negotiate, have a conversation with the managers on certain things it makes sense to standardize and centralize.
Yul Ejnes:Supplies is a great example. Even having you know medical assistant pools, whatever, but you know certain other things such as you know Doctor. X wants to see their new patients primarily in the morning or back to back versus doctor Y wants them spread out where the systems can accommodate that if management wants to. But the mantra is, well, standardized templates, make it simple for everyone to do their work except for the physician and their patients. So that would be another plea to management in terms of trying to make the professional feel more professional and not just like another widget that is part of a system that looks to make everything same.
Jeff Byers:Well, doctor Yul Ejness, that sounds like a great place to wrap up. Thanks, again for joining us on health fairs this week. I'm sure, conversations on the workforce will continue.
Yul Ejnes:Thanks so much, Jeff. I enjoyed talking about this.
Jeff Byers:Yeah. Yeah. But if you, the listener, enjoyed this episode, send it to the Rhode Island Red in your life, and we'll see you next week.