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This story is from the Anamnesis episode called I Quit and starts at 13:55 on the podcast. It's by Joseph Wiedermann, MD, an interventional cardiologist who specializes in complex coronary disease, multi-vessel coronary disease, and acute interventions for myocardial infarctions.
I had been in practice as an interventional cardiologist for 25 years. For most of my career, I was part of a small group practice in northern New Jersey, while also teaching at New York-Presbyterian Hospital in New York City. My practice initially started as a typical, privately owned, small group practice with three physicians specializing in high-risk interventional cardiology procedures while also performing diagnostic cardiac testing and general office cardiology.
Many of our patients have been with the practice for 20 years. We have become quite bonded both to the physicians in the practice and to the office staff who knew the patients very well and always responded to all calls and problems immediately.
Over many years we developed a very close relationship with our patients and viewed it as our primary responsibility to be immediately available to patient needs without ever limiting access or curtailing the time spent with an individual patient. This engendered a level of doctor-patient trust and even affection, which I felt was indispensable to providing good medical care.
Insane Loophole
Unfortunately, over the years, the changing nature of medical economics made it impossible for us to continue as an independent practice. At the current time, over 80% of cardiology practices in the U.S. have become hospital-owned due to a number of factors.
The primary cause was an insane loophole in reimbursement practices, which allows hospitals to charge far higher rates for diagnostic procedures than can be charged by individual physicians practices. Thus, while we were having trouble covering our salaries and staying afloat, the hospital, with its far higher reimbursement for exactly the same diagnostic testing, had a much easier path to profitability.
Accordingly, around 2012, we were forced to sell the practice to a local hospital in New Jersey. In our initial contract, it was laid out quite specifically that we would continue to practice medicine at our current office location.
The hospital would take over all billings and collections, but promised solemnly not to get involved in telling us how to practice medicine. Unfortunately, this contract also included a "poison pill," forbidding us to practice medicine within ten miles of our offices for two years if the contract was ever terminated.
This "non-compete" clause is illegal in many states. Unfortunately this remains legal in New Jersey and essentially functions as an inescapable trap.
No Escape Contract
Over the course of the first three years of the contract, the hospital pretty much lived up to its end of the bargain, as it continued to acquire local cardiology practices. However, by the time of the first renewal contract they had us in a position where we had little bargaining room.
We were forced to accept multiple additional responsibilities not included in the initial agreement. This is a fairly typical ploy among these rapacious hospitals. Suck the providers in with the initial contract and then tighten the screws when there's no escape.
I survived the second contract and continued to practice, but was far more constrained with regard to the amount of time I could spend with patients and saddled with an ever-expanding list of hospital administrative responsibilities which were forced upon us. During this contract, both of my other partners retired, leaving me with a solo practice, but still with my personally trained and truly fantastic office staff who were loved by our patients.
It was only when the time to re-sign the third contract came around that the hospital decided to completely change the rules of the game. They knew that my bargaining position was essentially nil.
They began by insisting that I move from my long-established office location. That spot was very convenient for many of my patients traveling from the Jersey Shore area. I had purchased my office space and essentially had no rent costs. The hospital wished to move me to a larger office owned by the hospital and shared with multiple other hospital-owned cardiology practices.
I found this inconvenient, but raised no objections because I felt it was within their rights to insist on a consolidation of practices if that was their economic decision.
It was only slowly and surreptitiously that their actual intent became obvious. After several meetings in the proposed new office space, it became clear that they intended to merge my solo practice into a multi-physician cardiology group that did not at all share my long-established practice patterns.
They also insisted on dispersing my patients, who I had cared for for over 20 years, indiscriminately across all the various practitioners in this new amalgamated practice. In addition, they were planning on taking my office staff, trained personally and exhaustively by me to fit my practice pattern and to provide the kind of patient interaction I insisted upon, and diffuse them among this large, communal practice.
As a result, my team -- the core of my practice and despite the high level of satisfaction my patients always expressed -- was to be scattered to the winds.
Unethical Take It or Leave It
Finally, as an added insult, they informed me that I was spending too much time with my patients and they needed to limit my office visits to 15 minutes throughout to maximize throughput. This was particularly ironic as they had just given me productivity bonuses for exceeding my RVU [relative value unit] targets over the last several years.
More importantly, it violated the first promise they made to us in the original contract, to never tell us how to practice medicine. Nothing could be a more fundamental interference in medical practice than telling you how to care for your own patients and how long to spend with each patient.
I was offered no room for negotiation and told it was a "take it or leave it" offer. From my perspective, they had decided to distribute my long-standing patients to strangers, forced me to join a group of physicians, some of whom did not meet my standards for patient care, and also obliged me to see my patients for visits so short, as to be frankly unethical.
It is impossible to provide good cardiac care to complex patients in a 15-minute visit. For these administrators to presume to tell me how to practice medicine was an utter outrage.
Accordingly, I said I could not agree to conditions I found unethical and they promptly fired me "without cause." Unfortunately, their contracts changed with every renewal as their doctors were sucked deeper into the hospital trap, and the contract now allowed them to fire me with no explanation required.
Despite the absence of cause for firing, the non-compete clause remained in effect. Since all the hospitals in my practice area were within the 10-mile exclusion zone, it became impossible for me to practice locally.
I could not open a local office as I would not be able to use any of the local hospitals. This also made it impossible for me to join any other local independent medical practices, despite multiple offers, as it is impossible to practice interventional cardiology without access to a local hospital.
Thus, the hospital had intentionally created a situation where they could fire me with impunity and steal all my patients. Despite obtaining extensive legal counsel, it was clear there was no way out of the trap they had cleverly constructed.
Accordingly, I was forced to pursue distant alternatives requiring me to leave my home and family for extended periods of time. I initially enrolled with a number of medical locums tenens agencies and found there was an active market for interventional cardiologists all over the country.
The local area was oversubscribed, and in any case, mostly blocked by the non-compete clause. Under these circumstances, I started looking for places where I could really be of use, particularly in underserved areas.
A Deeper Practice
Through Weatherby Healthcare, a large locums agency, I was offered a job on the island of Guam, a U.S. territory with previously no interventional cardiology services, but a new and well-equipped hospital looking to expand care for the people of Guam. The prospect of starting a new program and offering life-saving care to a population that had previously been decades behind the standard of care was extremely appealing and has proved to be extremely satisfying.
I have now been working on Guam at Guam Regional Medical City as chief of cardiology and director of the Cardiac Catheterization Laboratory. Over the last two years, I performed hundreds of lifesaving interventional procedures.
It is deeply joyful to be able to have such a clear impact on medical care and to care for the Guamanian people who are a warm and truly hospitable community which took me in like family. I plan to stay here for several more years and hopefully establish a self-sustaining cardiology program which will be able to serve the people of Guam for decades to come.
The only sadness I feel is for my long-established patients in New Jersey whom I was forced to abandon against my will. And also, frankly, a bit of loneliness as it's hard to be so far away from family and friends with only limited ability to go back home for vacations.
To my colleagues back home still in true, independent private practice, the few of them left, I would strongly advise them to never allow themselves to be swallowed by a hospital. To those already employed by hospitals on the mainland, I would suggest you watch your backs at all times and don't trust these folks for a second.
They don't care about you or your patients. They only care about maximizing hospital revenue and administrators' salaries, which have climbed into the millions as doctors' incomes decrease with every forced contract. I wish you all well and good luck to you all.
Other stories in the I Quit episode include Dying for the Fifth Time and My MD, My Baby, My Nightmare.
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