Waning Interest in Infectious Diseases Among Trainees: Is Medicine Pulling the Goalie?

Relatively low salaries in infectious diseases (ID) compared to other medical specialties, in a world where cost of living is skyrocketing, are an easy explanation for unmet needs of ID training programs to fill their positions. However, the interest in ID falling short of expectations may reflect that some features of the ID specialty are counter to select pervasive tendencies of modern culture, including (1) slow uptake of innovation into daily routines of ID practitioners, (2) the emphasis of clinical mastery of ID practitioners in an environment of medical corporatization and increased focus on revenue generation, and (3) the fact that ID practice takes societal interests into consideration (eg, prevention of antibiotic resistance) in a world dominated by rights of individuals, frequently at the expense of the common good. This article reflects on these possibilities to determine what steps can be taken to resurrect interest in our specialty.

Addressing the consequences of the corporatization of reproductive medicine.

In Australia and the UK, commercialization and corporatization of assisted reproductive technologies have created a marketplace of clinics, products, and services. While this has arguably increased choice for patients, 'choice', shaped by commercial imperatives may not mean better-quality care. At present, regulation of clinics (including clinic-corporations) and clinicians focuses on the doctor-patient dyad and the clinic-consumer dyad. Scant attention has been paid to the conflicts between the clinic-corporation's duty to its shareholders and investors, the medical profession's duty to the corporations within which they practice, and the obligations of both clinicians and corporations to patients and to health systems. Frameworks of regulation based in corporate governance and business ethics, such as stakeholder models and 'corporate social responsibility', have well-recognized limits and may not translate well into healthcare settings. This means that existing governance frameworks may not meet the needs of patients or health systems. We argue for the development of novel regulatory approaches that more explicitly characterize the obligations that both corporations and clinicians in corporate environments have to patients and to society, and that promote fulfilment of these obligations. We consider mechanisms for application in the multi-jurisdictional setting of Australia, and the single jurisdictional settings of the UK.

Ophthalmologist Turnover in the United States: Analysis of Workforce Changes from 2014 through 2021.

PURPOSE: Physician turnover is costly to health care systems and affects patient experience due to discontinuity of care. This study aimed to assess the frequency of turnover by ophthalmologists and identify physician and practice characteristics associated with turnover. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Actively practicing United States ophthalmologists included in the Centers for Medicare and Medicaid Services Physician Compare and Physician and Other Supplier Public Use File between 2014 and 2021. METHODS: We collected data for each ophthalmologist that was associated with practice/institution and then calculated the rate of turnover both annually in each year window and cumulatively as the total proportion from 2014 to 2021. Multivariable logistic regression analysis was used to identify physician and practice characteristics associated with turnover. We also evaluated turnover characteristics surrounding the Coronavirus disease 2019 (COVID-19) pandemic. MAIN OUTCOME MEASURES: Ophthalmologist turnover, defined as a change of an ophthalmologist's National Provider Identifier practice affiliation from one year to the next. RESULTS: Of 13 264 ophthalmologists affiliated with 3306 unique practices, 34.1% separated from at least 1 practice between 2014 and 2021. Annual turnover ranged from 3.7% (2017) to 19.4% (2018), with an average rate of 9.4%. Factors associated with increased turnover included solo practice (adjusted odds ratio [aOR], 9.59), university affiliation (aOR, 1.55), practice location in the Northeast (aOR, 1.39), and practice size of 2 to 4 members (aOR, 1.21; P < 0.05 for all). Factors associated with decreased turnover included male gender (aOR, 0.87) and more than 5 years of practice: 6 to 10 years (aOR, 0.63), 11 to 19 years (aOR, 0.54), 20 to 29 years (aOR, 0.36), and ≥ 30 years (aOR, 0.18; P < 0.05 for all). In the initial year (2020) of the COVID-19 pandemic, annual turnover increased from 7.8% to 11.0%, then decreased to 8.7% in the postvaccine period (2021). CONCLUSIONS: One-third of United States ophthalmologists separated from at least 1 practice from 2014 through 2021. Turnover patterns differed by various physician and practice characteristics, which may be used to develop future strategies for workforce stability. Because administrative data cannot solely determine reasons for turnover, further investigation is warranted given the potential clinical and financial implications. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Norms and Corporatization of Medicine Influence Physician Moral Distress in the United States.

PhenomenonMoral distress, which occurs when someone's moral integrity is seriously compromised because they feel unable to act in accordance with their core values and obligations, is an increasingly important concern for physicians. Due in part to limited understanding of the root causes of moral distress, little is known about which approaches are most beneficial for mitigating physicians' distress. Our objective was to describe system-level factors in United States (U.S.) healthcare that contribute to moral distress among pediatric hospitalist attendings and pediatric residents.ApproachIn this qualitative study, we conducted one-on-one semi-structured interviews with pediatric hospitalist attendings and pediatric residents from 4 university-affiliated, freestanding children's hospitals in the U.S. between August 2019 and February 2020. Data were coded with an iteratively developed codebook, categorized into themes, and then synthesized.FindingsWe interviewed 22 hospitalists and 18 residents. Participants described in detail how the culture of medicine created a context that cultivated moral distress. Norms of medical education and the practice of medicine created conflicts between residents' strong sense of professional responsibility to serve the best interests of their patients and the expectations of a hierarchical system of decision-making. The corporatization of the U.S. healthcare system created administrative and financial pressures that conflicted with the moral responsibility felt by both residents and hospitalists to provide the care that their patients and families needed.InsightsThese findings highlight the critical role of systemic sources of moral distress. These findings suggest that system-level interventions must supplement existing interventions that target individual health care providers. Preventing and managing moral distress will require a broad approach that addresses systemic drivers, such as the corporatization of medicine, which are entrenched in the culture of medicine.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: Corporatization and the rise of private equity in dermatology.

Within the past 2 decades, for-profit financial groups have become increasingly involved in health care. Outlier dermatology practices with high volumes of well-reimbursed procedures are attractive to consolidation backed by private equity. With fewer choices for independent or group private practice, junior dermatologists are increasingly seeking employment without ownership in private equity-backed corporate groups whose primary fiscal responsibility lies with their investors. Medicare's response to corporatization and consolidation has already changed the practice of dermatopathology. Dermatologists should be aware of this history, given the ability of corporations and private equity groups to shape the present and future of our field.

Venture Capital in US Medicine: A Briefing for Radiologists.

In recent years, there has a been a rapid and significant drop in the number of private practices in US radiology. Many factors have driven this change. One of the most important has been the corporatization of practices. In many cases, this involves third-party financing, one type of which is venture capital. This article will provide an introduction to the venture capital investment model for medical professionals.

Seven Challenges in Radiology Practice: From Declining Reimbursement to Inadequate Labor Force: Summary of the 2023 ACR Intersociety Meeting.

This white paper discusses the seven most important challenges facing radiology today: declining reimbursement, corporatization and consolidation, inadequate labor force, imaging appropriateness, burnout, turf wars with nonphysicians, and workflow efficiency. Participants in the Intersociety Summer Conference-2023 focused their effort on identifying potential solutions given how critical these topics are to the sustainability of the profession.

Financial Health of Private Equity-Backed Groups: Perspectives From Eye Care.

BACKGROUND: In private equity (PE) buyouts of medical practices, it is common for the PE firm to raise significant levels of debt in order to finance the purchase. This debt is subsequently shouldered by the acquired practice(s). There remains a scarcity of literature quantifying the effect of PE acquisition on the subsequent financial performance of eye care practices. We aim to identify and characterize debt valuations of ophthalmology and optometry private equity-backed group (OPEG) practices, which serve as an indicator of practice financial performance. METHODS: A cross-sectional study from March 2017 to March 2022 was conducted using business development company (BDC) quarterly/annual filings to the Securities and Exchange Commission (SEC). The 2021 BDC Report was used to identify all BDCs actively filing annual reports (Form 10-Ks) and quarterly reports (Form 10-Qs) in the United States in 2021. The public filings of BDCs lending to OPEGs were searched from the inception of the OPEG's debt instrument in a BDC's portfolio and the amortized cost and fair value of each debt instrument were tabulated. A panel linear regression was used to evaluate temporal changes in OPEG valuations. RESULTS:  A total of 2,997 practice locations affiliated with 14 unique OPEGs and 17 BDCs were identified over the study period. Debt valuations of OPEGs decreased by 0.46% per quarter over the study period (95% CI: -0.88 to -0.03, P = 0.036). In the COVID-19 pre-vaccine period (March 2020 to December 2020), there was an excess (additional) 4.93% decrease in debt valuations (95% CI: -8.63 to -1.24, P = 0.010) when compared to pre-pandemic debt valuations (March 2017 to December 2019). Effects of COVID-19 on valuations stabilized during the pandemic post-vaccine period (February 2021 to March 2022), with no change in excess debt valuation compared to pre-pandemic baseline (0.60, 95% CI: -4.59 to 5.78, P = 0.822). There was an increase in practices that reported average discounted debt valuations from 20 practices (1.6%) associated with one OPEG to 1,213 practices (40.5%) associated with nine OPEGs (including 100% of newly acquired practices), despite the stabilization of COVID-19-related excess (additional) debt. CONCLUSIONS: Debt valuations of eye care practices have declined significantly post-PE investment from March 2017 to March 2022, suggesting that the financial health of these groups is volatile and vulnerable to economic contractions such as the COVID-19 pandemic. Eye care practice owners must consider long-term financial risks and impacts of subsequent patient care when selling their practice to a private equity group. Future research should assess the impact of secondary transactions of OPEGs on the financial health of practices, practitioner lifestyle, and patient outcomes.

Privatization, Corporatization, and Public-Private Partnership in the Kingdom of Saudi Arabia.

There are different governmental reasons and technologies for seeking public-private partnerships throughout the developed countries. Significant motives have been to improve efficiency and risk distribution in comparison to traditional financing techniques and to lessen budget and borrowing limits. In this study, the movement toward privatization enhancing the efficiency of MoH's hospitals has been assessed using Data Envelopment Analysis (DEA) from 1979 to 2020. Moreover, the efficiencies of the individual hospital were estimated through the DEA model, which includes: scale efficiency (SE), pure technical efficiency (PTE), and overall technical efficiency (OTE). In addition, factor affecting such efficiencies was analyzed through Tobit regression. The VRS results suggest that the numbers of hospitals benefiting from the complete corporatized phase are greater than those benefiting from the last phase (and vice versa in the case of DRS). The variance between inefficient hospitals in the less corporatized phase (2000-2020) was more prominent than in the fully corporatized phase (1988-1999). In conclusion, fully corporatized hospitals (on average) achieve relatively better overall efficiency. It is recommended that additional corporatization might be stimulated by a standardized set of performance measures, which cover both the quality criteria and economic efficiency measurements from a healthcare perspective.

Storylines, metaphors, and solutions in the work-readiness literature: A frame analysis.

AIM: To investigate how the literature frames the reported poor work-readiness of new graduate nurses and the solutions it recommends. DESIGN: Critical frame analysis of work-readiness literature storylines. METHODS: Deductive and inductive analysis of work-readiness literature published 2016-2019. RESULTS: The three systematic reviews, literature review, and analysis of transition guidelines reinforced the belief that nursing graduates should be work-ready. In addition, the articles summarized service and academic innovations intended to assist newly qualified nurses transition to practice. CONCLUSION: The literature attributes perceived graduates' poor work-readiness to divergent faculty and employer expectations, personal deficiencies, defective learning environments, and poor workplace support. Internships, mentorship, academic-service partnerships, and curricular and pedagogical innovation are the dominant recommendations for reform. Workplace clinical education and training are not mechanisms for correcting graduates' work performance but essential activities for sustaining the nursing workforce. IMPACT: The study should encourage more use of frame analysis in nursing education research. Fact-checking storylines must be a priority for future studies. Research that clarifies the fault lines between advocates of work-readiness and dissident academic leaders has the potential to promote dialogue. Work-ready, theory-gap, and other deficit metaphors must be put aside for the debate because universities must not relinquish their responsibility for educating students for the 21st century.

Radiologist-Practice Separation: Recent Trends and Characteristics.

PURPOSE: To assess recent trends and characteristics in radiologist-practice separation across the United States. METHODS: Using the Medicare Physician Compare and Medicare Physician and Other Supplier Public Use File data sets, we linked all radiologists to associated group practices annually between 2014 and 2018 and assessed radiologist-practice separation over a variety of physician and group characteristics. Multivariate logistic regression modeling was used to estimate the likelihood of radiologist-practice separation. RESULTS: Of 25,228 unique radiologists associated with 4,381 unique group practices, 41.1% separated from at least one group practice between 2014 and 2018, and annual separation rates increased 38.4% over time (13.8% from 2014 to 2015 to 19.2% from 2017 to 2018). Radiologist-practice separation rates ranged from 57.4% in Utah to 26.3% in Virginia. Separation rates were 42.8% for general radiologists versus 38.2% for subspecialty radiologists. Among subspecialists, separation rates ranged from 43.0% for breast imagers to 33.5% for cardiothoracic radiologists. Early career status (odds ratio [OR] = 1.286) and late (OR = 1.554) career status were both independent positive predictors of radiologist-practice separation (both P < .001). Larger practice size (OR = 0.795), radiology-only (versus multispecialty) group (OR = 0.468), academic (versus nonacademic) practice (OR = 0.709), and abdominal (OR = 0.820), musculoskeletal (OR = 0.659), and neuroradiology (OR = 0.895) subspecialization were independent negative predictors (all P < .05). CONCLUSIONS: With over 40% of radiologists separating from at least one practice in recent years, the US radiologist workforce is highly and increasingly mobile. Because reasons for separation (eg, resignation, practice acquisition) cannot be assessed using administrative data, further attention is warranted given the manifold financial, operational, and patient care implications.

Radiology Practice Consolidation: Fewer but Bigger Groups Over Time.

PURPOSE: The aim of this study was to assess recent trends in US radiology practice consolidation. METHODS: Radiologist practice characteristics were obtained from the Medicare Physician Compare database for 2014 and 2018. Radiologists were classified on the basis of their largest identifiable practice affiliations. Single-specialty radiology practices were identified using practice names. Temporal trends in practice sizes were assessed. RESULTS: At the individual radiologist level from 2014 to 2018, the fraction of all radiologists in groups with 1 or 2 members declined from 3.2% to 2.1%, 3 to 9 members from 10.2% to 6.7%, 10 to 24 members from 18.2% to 14.1%, 25 to 49 members from 16.6% to 15.1%, and 50 to 99 members from 13.3% to 11.5%. In contrast, the fraction in groups with 100 to 499 members increased from 15.7% to 21.8% and with ≥500 members from 22.9% to 28.7%. At the practice level, the fraction of all radiologists' practices with 1 or 2 members decreased from 26.9% to 22.8%, whereas the fraction with 100 to 499 members increased from 7.6% to 10.2% and with ≥500 members from 2.5% to 4.1%. Similar shifts were present for single-specialty radiology practices and all geographic regions nationally. The 30,492 radiologists identified in 2014 were affiliated with 4,908 group practices, including 2,812 single-specialty practices. In comparison, the 32,096 radiologists identified in 2018 were affiliated with 4,193 group practices (a 14.6% decline), including 2,216 single-specialty practices (a 21.2% decline). CONCLUSIONS: In very recent years, the US radiologist workforce has consolidated, leading to increased practice sizes and a substantial decline in the number of distinct practices, disproportionately affecting single-specialty radiology practices. The impact of this consolidation on cost, quality, and patient access merits further attention.

Hybrid Organizations in Health Systems: The Corporatization of Malaysia's National Heart Institute.

Health system reforms across high- and middle-income countries often involve changes to public hospital governance. Corporatization is one such reform, in which public sector hospitals are granted greater functional independence while remaining publicly owned. In theory, this can improve public hospital efficiency, while retaining a public service ethos. However, the extent to which efficiency gains are realized and public purpose is maintained depends on policy choices about governance and payment systems. We present a case study of Malaysia's National Heart Institute (IJN), which was created in 1992 by corporatization of one department in a large public hospital. The aim of the paper is to examine whether IJN has achieved the goals for which it was created, and if so, whether it provides a potential model for further reforms in Malaysia and other similar health systems. Using a combination of document analysis and key informant interviews, we examine key governance, health financing and payment, and equity issues. For governance, we highlight the choice to have IJN owned by and answerable to a Ministry of Finance (MOF) holding company and MOF-appointed board, rather than the Ministry of Health (MOH). On financing and payment, we analyze the implications of IJN's combined role as fee-for-service provider to MOH as well as provider of care to private patients. For equity, we analyze the targeting of IJN care across publicly-referred and private patients. These issues demonstrate unresolved tensions between IJN's objectives and public service goals. As an institutional innovation that has endured for 28 years and grown dramatically in size and revenue, IJN's trajectory offers critical insights on the relevance of the hybrid public-private models for hospitals in Malaysia as well as in other middle-income countries. While IJN appears to have achieved its goal of establishing itself as a commercially viable, publicly owned center of clinical excellence in Malaysia, the value for money and equity of the services it provides to the Ministry of Health remain unclear. IJN is accountable to a small Ministry of Finance holding company, which means that detailed information required to evaluate these critical questions is not published. The case of IJN highlights that corporatization cannot achieve its stated goals of efficiency, innovation, and equity in isolation; rather it must be supported by broader reforms, including of health financing, payment, governance, and transparency, in order to ensure that autonomous hospitals improve quality and provide efficient care in an equitable way.

Early-Career Radiologists' Perceptions of National Corporations in Radiology.

PURPOSE: Radiology, like many medical specialties, has experienced an increase in nationalized corporatization. The most vulnerable cohorts affected by this trend are early-career radiologists (ECRs), including trainees and recent graduates, particularly those entering or who have recently entered private practice. The aims of this study were to examine the awareness and perspectives of ECRs regarding this trend and to share salient examples of the impact of corporatization. METHODS: From February 20, 2019, through May 28, 2019, an online survey of the members of the ACR's Resident and Fellow Section and Young and Early Career Professional Section was conducted. Respondents were queried about their awareness of corporatization, their opinions of how it affects radiology, their preferred practice type, whether they know other ECRs affected by corporatization, and whether they worry about their practices or future practices being acquired. A free-response opportunity was also provided for respondents to share their relevant personal experiences. RESULTS: A total of 602 ECRs returned completed surveys. Of this total, 85% of respondents were aware of national corporatization, 86% believe that corporate entities harm radiology as a specialty, 83% prefer to join independent private practices with 79% wanting to be involved in leadership or business, and 72% worry about their practices or future practices being acquired by national entities. Twenty-five percent of respondents submitted unique free responses regarding their experiences with corporatization. CONCLUSIONS: The majority of ECRs surveyed have negative perceptions of corporatization in radiology, prefer to join independent practices, and worry about their practices selling to national corporations.

Challenges in the Era of Coding and Corporatization.

The past 40 years have witnessed a major redesign of health care, largely driven by rampantly increasing costs and the perception of lack of better outcomes to justify those costs. Many demographic changes have also challenged the women's health care provider workforce, and evolving new payment systems are likewise a source of angst for these providers. Managed care is seeking to cut costs, and the challenge is to do so without sacrificing quality. Burnout is a new challenge in the present environment. There is now an opportunity to meet these challenges and provide the excellent care our patients deserve.