The Integrated Health Care System Practice

Little is known about the effect of practice setting in job satisfaction and physician burnout in cardiology. The results of a survey, published in 2019 in the Journal of the American College of Cardiology, demonstrated that neither cardiovascular subspecialty nor practice setting had an impact on burnout rates. However, dissatisfaction with a practice setting could be a potential source of work frustration, job dissatisfaction and ultimately burnout. Therefore, there is an impetus for trainees to understand the different practice settings to tailor one's job search and increase the chances of job satisfaction after completing fellowship training.

An increasingly common practice setting is a fully integrated practice where a group of cardiologists are clinically and financially tied to a health care system. This setting has several potential advantages and disadvantages.

The Advantages

A fully integrated system affords the opportunity to develop one's professional area of expertise and professional persona by assuming administrative responsibilities akin to one's clinical interest. Carving out such a nonclinical niche helps the physician both understand and be a stakeholder in decisions affecting subspecialty areas of cardiology. In a non-relative value units (RVU)-based model, the co-existence of such hybrid positions allows for better alignment of the clinical work with the overarching goals of the organization. Simultaneously, the physician participation in administrative forums informs hospital administrators about the resource needs for improvement in health care delivery and program development.

Another advantage of the integrated health system includes the opportunity to assume administrative roles that can affect the institution as a whole and a larger number of patients than in a private practice setting. Some organizations offer physician leadership development courses, which can serve as potential launching pads for other leadership roles in hospital administration.

Some hospitals have cardiology fellowship and internal medicine residency training programs. The presence of trainees in daily practice allows the physician to develop an academic or pseudo-academic role and fosters continuous exposure to new concepts in cardiology literature and medical education. This feature also helps keep cardiologists (in all stages of their career) abreast of the ever-changing cardiology knowledge. Working with interns, residents and fellows also allow opportunities to develop quality improvement and research projects. This might spur scientific manuscript publications without the expectations of grant funding, which is often required in some professional tracks at academic institutions. Some community based hospitals have research administration departments that offer statistical analysis services to support research derived from practicing clinicians.

The Disadvantages

Multiple financial compensations models exist in hospital or health care system integrated practices. Compensation in these practices tends to be lower than in private practice. Therefore, in the search of a fully integrated position, it is important to inquire whether group physicians are part of the governance bodies or committees that affect the group compensation. It is crucial to maintain such group representation to advocate for the physician group in the drafting of initial and renewal contracts.

Another important element is whether bonuses or merit increases are based on productivity or value-metrics. RVU models incentivize clinical productivity while value-metric models value both the clinical and the nonclinical contributions of the group members and their participation in hospital committees aimed at improving quality of care, patient satisfaction, and hospital or unit length of stay. The participation of group members in these committees ultimately helps both reimbursement and the status of the hospital by improving metrics surveyed by regulatory agencies.

Administrative responsibilities could become a burden if there is no clear delineation of the percentage of the physician's effort that should be protected to be able to accomplish nonclinical tasks.

We do not know for sure whether practice setting affects cardiologist burnout but it makes intuitive sense that practice-related job frustrations and dissatisfaction may contribute.

The multifaceted aspect of a fully integrated health care system practice may offer a well-balanced opportunity to decrease burnout.

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This article was authored by Antonio B. Fernandez, MD, FACC, director of the Cardiac ICU at Hartford Hospital in Hartford, CT.