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Internal medicine physician Corinne Rao discusses the article, “The Faustian bargain of modern medicine.” In this episode, Corinne explores the modern health care system’s trade-offs, comparing the traditional independence of private practice to the constraints of employed settings that offer financial stability and reduced administrative burdens at the cost of professional autonomy. She examines how these compromises affect the patient-physician relationship, contribute to burnout, and challenge the core values of medical practice, offering actionable insights for physicians seeking to balance immediate benefits with long-term professional integrity.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Corinne Rao. She’s an internal medicine physician, and her latest article is “The Faustian bargain of modern medicine.” Corinne, welcome back to the show.
Corinne Rao: Thank you for having me back, Kevin.
Kevin Pho: All right, so tell us what your latest article is about.
Corinne Rao: So my latest article is basically about physicians being employed. There are figures that are showing us that over the last few years, especially at the start of the COVID pandemic and after, that more and more physicians are becoming employed by hospitals, health systems, and corporate entities. So that number has become somewhere like 75 to 77 percent, depending on where you are looking at.
And those are the latest numbers. This is a huge jump from before, when there were a lot more independent physicians. There were physician groups that were owned by physicians and operated and managed. And it is just something that I have been thinking about and seeing whenever I talk to a lot of physicians during going to different facilities and meetings.
And it led me to wonder—I think everybody kind of feels it is not a good thing, but I started thinking, is this like the story of Dr. Faust, Faustus, who basically made a deal with the devil? It sounds a little dramatic, but the bottom line is, are we making a bargain in order to be employed, and what are we giving up? So that is basically what the article is exploring.
Kevin Pho: All right. And when you say that something like in the high 70 percent of physicians are being employed, in most cases, they are being employed by academic medical centers, hospitals, large health care systems. Why do you think that number has been rising over the last few decades?
Corinne Rao: I think, Kevin, the landscape is shifting. Things are becoming more complex for all kinds of reasons, and that includes legal, regulatory, financial—just all kinds of reasons. And it has become really difficult for physicians to maintain an independent practice because they are bearing quite a bit of the burden to meet all these regulatory requirements to start with.
And I think they make the jump because they feel that is one way for them to keep practicing and stay in the game. So I think it is a whole bunch of factors that are contributing. And it has been over time. I do not think it is something that just happened overnight. But this is kind of the trend that we are seeing.
Kevin Pho: So you framed this as a Faustian bargain. Why do you think that is, for those physicians who proverbially make that deal, perhaps for short-term gain, but what are some of the long-term consequences?
Corinne Rao: There are a lot of consequences, and that is the reason I compared it to being a Faustian bargain, because I have to feel that it leads to loss of autonomy, and there are two competing entities here. There is the physician, and as you know, being a fellow physician, our responsibility and our job—really, our training—consists of doing what is best for the patient, what is in their best interest. And corporate entities, health systems, they have a fiduciary responsibility to their shareholders, to a back company.
I do not think you can really combine the two because there is going to be a diverging interest there. And what that leads to is when we sign on as being employed, basically we are giving up a lot of our autonomy: our autonomy in terms of time, the time we may spend with patients, the time we have to do all of our responsibilities. And it is just really hard for me to see how that leads to better patient care.
So that is why I was comparing it, because we have to give up something, and I think what we are giving up here is our autonomy. And when we give up that autonomy…
Kevin Pho: When you talk to these physicians in these conferences who are employed, in general, are they happy with the arrangement? What is some of the feedback that they are giving you?
Corinne Rao: It is all over the place, because in many cases, when we are in training or we are coming out of training, we do not have a lot of experience in thinking outside the box when it comes to our own careers. They do not really train us or give us much information. So physicians tend to think only in terms of having to sign an employment agreement, and that is going to give them a somewhat stable salary and benefits. And keep in mind that they are coming out with a lot of debt in some cases or having spent a lot of money to get that education, and definitely a lot of time.
So there is that pressure, and this seems to be—many of them think that is the only path. Many of them do not seem to realize that there are other ways, but I think more and more are realizing there are other ways to practice medicine on your own terms. It is just going to be, what can you do to reach that point, and what is going to work for you, because everybody’s situation is different.
As far as feeling happy with their choices, I am seeing a lot of dissatisfaction because at first you have what you call the honeymoon period: everything is good, you are being welcomed. And then over time, there is just more and more being asked of you, and there is not more and more time. So something has to give, and there is fatigue, there is burnout, and there is just a lot of dissatisfaction.
Kevin Pho: Can there be a scenario when a physician is working in an employed model yet still maintain that autonomy? Is that even a possibility, or are those just two competing tensions that can never get along?
Corinne Rao: It is a tough question, because I think it is two competing entities, and it is hard to correlate both at the end of the day because you just do not have enough hours in the day to do everything that we are asked to do, as well as do everything that is best for a patient. So I think there are two competing entities.
I am just going to add here, Kevin, that I am not by any means suggesting that every employer or every hospital is not good—that is not at all what I am suggesting—or that there are not physicians who are pretty happy with where they are at. But the general feeling is that there is a lot they are giving up by signing those contracts.
And you can see that in just the way these contracts are structured or are changing, because I have been here for a long time, and I have been on both sides. I have been employed, and for the last few years, I have been by myself, independent. And for me, anyway, I see now that the independent side is better. There is risk involved to it, obviously, but I think there is risk involved in anything we do.
Kevin Pho: So let us talk about some of those risks because, as you mentioned, almost 80 percent of physicians are in an employed model, and it is becoming increasingly difficult to become an independent practicing physician because you have to compete with bigger and bigger hospital systems, academic medical centers, and whatnot. Talk about some of the challenges. How realistic is it for physicians to choose an independent model when there are just so many large entities that they would have to compete against?
Corinne Rao: So we have to step back and look at what are the options, and I am happy to say that I do also meet many physicians that are doing very many different things. So it does not have to be one or the other. You can be exploring a lot of other options that would allow you to be independent. So maybe you cannot just open your own practice and be busy from day one, but would you start looking at a somewhat hybrid practice? Would you start doing some shifts for locums? What can you do? There are so many options.
There are physicians that are doing all kinds of things. They are in nonclinical scenarios; they are exploring those options, and there is a whole spectrum of those, from chart reviews done remotely to being a medical expert witness to being in pharma, where they have physicians helping them. So there are a lot of options. It just depends on what you want to do, what you are looking at.
Yes, if you are looking at a traditional practice, it is challenging because there are things to deal with like insurances, regulations, so many things. So your overhead is going to be high. That would be challenging, no doubt. But there are so many other ways to explore being independent.
Kevin Pho: Now, like you mentioned earlier, a lot of newly graduated physicians are graduating with hundreds of thousands of dollars in debt. Do you think that they are willing to take some of that uncertainty, some of the risks that you mentioned—whether it is a hybrid practice or independent practice—when they have so much in debt?
Corinne Rao: It is very difficult, no doubt. And I do not say this lightly when I say that it is a Faustian bargain, but I think that it is OK for them to jump into their first job, but you also want to be open to looking around you and learning of other possibilities. You just cannot keep the blinkers on and go down one path. So it is definitely challenging. But I have actually seen a couple of younger physicians who are right out of residency doing that, and it has been very encouraging to talk to them and see that the path they are taking is not the traditional one.
Kevin Pho: As you mentioned earlier, a lot of physicians in training typically train in academic medical centers, so they are only exposed to one style of medicine. It is not like private practice physicians or independent physicians go in and talk with them. So how can they get exposed to some of these different models of practice and maybe consider some options that they ordinarily would not have thought of?
Corinne Rao: I think they just have to network with other physicians. They have to have mentors who are attending physicians at different stages of their careers. I myself have had the opportunity to have medical students and residents, even as an independent contractor at a couple of my facilities. And if they ask me stuff, I try to talk to them about those things, too. Because, to be honest, they can learn about congestive heart failure and hypertension from many of their regular didactic sessions, but nobody is going to tell them what to look for in a contract or what to look for when you are graduating. So there are many ways for them. I think they have to take advantage of the mentors who are around them, and I think they have to stay engaged and look around and just explore or just look at what are the other possibilities.
Kevin Pho: What do you think is going to happen going forward? Over the last decade, the number of employed physicians is almost reaching 80 percent—you said it is in the high 70s. Do you see that trend continuing? And if so, what does that mean for those who want to practice independently?
Corinne Rao: What is happening is that there is dissatisfaction growing with the choices that we have made. So eventually, I think the pendulum is going to start swinging back. Whether it is going to happen in our lifetime, I do not know, but even just to see the needle moving would be encouraging. And I think we are going to see that. I just do not see it being sustainable at the rate it is going.
The other side of this, Kevin, is that a lot of physicians, with the burnout and everything, are retiring early or leaving clinical medicine. So it is actually an important thing to think about when we look at what are the causes of dissatisfaction. That is why we have to explore these issues—even though it is so complicated, we have to look at them—because it is just going to lead to more people giving up and quitting.
Already, the physician workforce is aging. I forget the exact numbers, but there is a large percentage of us who are over the age of 55, so they are not going to work forever. So it is all leading to an unsustainable level where we have to ask, are we going to get the care that we need from a physician? It is kind of a scary thought, so I hope that the pendulum is going to swing back. How long it is going to take is anybody’s guess.
Kevin Pho: We are talking to Corinne Rao. She is an internal medicine physician. Today’s KevinMD article is “The Faustian bargain of modern medicine.” Corinne, let us end with some take-home messages that you want the KevinMD audience to know.
Corinne Rao: Kevin, my take-home message is that in this changing landscape, just think about what you are signing on with and decide what is important for you. In the end, I think—is it possible to avoid a Faustian bargain? Yes, it is. So I hope that each one of us can think about what is important to us and kind of go with that. So that would be my take-home message.
Kevin Pho: Great. Thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Corinne Rao: Thank you for having me, Kevin. It has been a pleasure.
