Friday, April 2, 2021

Microaggression In Anesthesiology? Try Macroaggression.

 

An article published in JAMA Surgery recently listed the level of microaggression present in a group of surgeons and anesthesiologists at Southern California Permanente Medical Group in Irvine, CA. Out of 588 respondents to a survey, a large majority expressed some level of microaggression in their workplace.

The results were measured with different ratings scales. There is the Maslach Burnout Inventory (MBI), the Racial Microaggression Scale (RMAS), and the Sexist Microaggression Experience and Stress Scale (Sexist MESS). I didn't even know that somebody had invented actual legitimate ratings to measure microaggression.

Of 259 female physicians who responded to the survey, 245 of them reported feeling microaggression at work. That's a vast 94%. The most common microaggressive act was "environmental invalidation" or seeing and hearing degrading images about women. This was reported in 86% of female respondents. The next most common microaggression, experienced by 74% of females, was "leaving gender at the door" or having to overcompensate for being female or hiding their emotions and femininity at work. So women feel they are the victims of microaggression if they are not allowed to display their feminine side at work yet are slighted if you complement their looks. Got it.

Among racial minorities, the most common microaggression was not having a role model of the same race at work, which happened to 67% of respondents. This feeling was more prevalent among female physicians (74%), underrepresented minorities (90%), and South Asian physicans (70%). The second most common racial microaggression reported at 51% was feeling like being treated as a foreigner or 'not a true American'. This was most commonly reported by females (58%), Asian (57%), South Asian (60%), and Middle Eastern (54%).

Wow people get their feelings hurt really easily these days. You don't like it when you have to check your gender at the door? Your ego is bruised when the chairman of your department is not the same ethnicity as yourself? Give me a break. How about trying some real macroaggression, the kind of mano a mano conflicts that can happen between an anesthesiologist and the surgeon. Next time you feel like you're depressed because the surgeon told a dirty joke, read about a real life fistfight between the anesthesiologist and surgeon in the operating room while the patient is asleep. That's when men were men and... oops did I step over the line and present too much microaggression for my readers? I guess I better sign up for my hospital's Anger Management class to check my microaggression.

Wednesday, March 31, 2021

Anesthesiology Is An Elite Residency


It doesn't get much more competitive than this. Match Day 2021 has come and gone and anesthesiology has once again shown itself to be an elite residency. Out of 1,893 PGY1 and PGY2 positions available in the NRMP Match for anesthesiology, there were only three unfilled spots. That's a match rate of 99.8%. This is an improvement from 99.4% last year.

How difficult is it to match in anesthesiology? Let's compare it to other programs that are considered extremely competitive. Dermatology had six unfilled spots in the match. Emergency Medicine had fourteen unfilled positions. Radiology, part of the previously exclusive ROAD programs, had eleven.

This news is even better (or worse if you're applying for an anesthesiology residency) when you consider that the number of residency positions has been increasing every year. This year, there were 1,460 PGY1 spots available in the match. That compares with 1,370 last year and only 1,202 in 2017. 

The reason there are so few unfilled positions is that anesthesiology is becoming more popular with medical school students. This year, 5.6% of US MD seniors went into anesthesiology. That compares with 5.2% last year and only 4.6% in 2017. Despite the fact that there are more anesthesiology residency programs offering more positions than ever before, there doesn't appear to be any oversupply of residency spots yet.

The anesthesia residents aren't having any trouble finding a job either when they graduate. The job market right now for anesthesiologists is hotter than ever. From our own personal experience, we can't hire anesthesiologists fast enough, even as we're hiring CRNA's at the same time.

So congratulations to all the medical students who matched into anesthesiology. You have accomplished one of the most difficult tasks in med school. You're on your way to becoming one of the most highly sought after physicians in the medical field. You're not going to regret it.

Saturday, March 27, 2021

My Tumultuous 2020

 

This is the conclusion of my series on my tumultuous 2020. While I was very lucky and didn't suffer any personal loss from the covid pandemic, the year was nevertheless one of the most unpredictable and contentious in my career.

When 2020 first started, I thought I was going to to have another routine banner year. The operating rooms were full. We were working hard, but getting paid handsomely. I had just run my first half marathon. The Wuhan virus was a disturbance in a faraway land that didn't seem to have any significance on this side of the Pacific. It was so inconsequential that Los Angeles proceeded with their marathon in early March. Then just a few days later, everything stopped.

Our incomes dropped over fifty percent over the next six weeks. The operating rooms practically shut down as images from Italy and New York haunted every doctor on the planet. We learned how to wear N95 masks and don and doff PPE's. Different treatments for covid came and went each week with no clear understanding if any of it worked. We all took out PPP loans from the government to keep from going bankrupt. The stock market had its fastest drop into a bear market in history. It was a darkness that we didn't know when or if it would let up.

Then spring brought a bit of a respite. The state governor allowed hospitals to start accepting elective cases again. Our operating rooms slowly began gearing up to do elective surgeries. But before long there came another surge. This time instead of shutting down the OR's, the administration took a more measured approach by limiting, not eliminating cases. As long as the hospital census was not overwhelmed with covid patients the OR's could continue to run. 

Our anesthesia group could see this was going to be problematic for an indefinite amount of time. We couldn't let a disease dictate the economic well being of the group or the group's partners. It was time to change economic models. The group that I joined almost two decades ago was shockingly disappearing. We were going to get taken over and become employees, no longer the master of our destinies. My dreams of coming to work every day and working the same way for thirty years until I retire had been upended by a virus. Medicine's relentless march towards consolidation of physicians' groups and hospital systems was being abetted by a disease.

It took months of departmental meetings and contentious zoom chats but almost all of us signed on the dotted line and overnight became hospital employees. There were pros and cons to the new job, but the biggest adjustment was the introduction of CRNA's to the department. I think our anesthesiologists needed more education on the new system than the CRNA's. They had worked elsewhere with an anesthesia care team model while we had never had one. This is still an ongoing process within the group as we all adjust and try to make the system as efficient and profitable for the hospital as possible. 

If any of you had wondered why I hadn't posted for several months, it's because of all these changes going on in my life. It was very stressful and caused me physical symptoms like weight gain and flareups of my eczema. We are still adjusting to the ACT model but we don't have a choice anymore. We no longer decide our own careers. It's dictated to us and we have to make it work or leave. This is my first taste of corporate medicine and it's a bitter pill to swallow.

Friday, March 26, 2021

How CRNAs Could Eventually Supplant Physician Anesthesiologists

 


After working with CRNA's for several months, what is the main problem that I think is going to affect our group? So far, it's not the quality of their work. They're all competent in the OR and some are actually very good, dare I say even better than a few anesthesiologists we have in the department. We haven't had any issues with bad attitudes or incompetence. The problem with having CRNA's in the department is not that there is anything wrong with the nurses per se. It's the way the system is set up so that it diminishes the role of the anesthesiologist. What do I mean by that?

When supervising CRNA's, the anesthesiologist becomes more like a perioperative physician's assistant than a physician. We examine the patients in preop. We make sure the IV's are in place. We go over the findings with the CRNA and implement an anesthesia plan that we don't actually carry out. It's the nurse in the room that is giving the anesthesia. What goes on during the surgery is almost completely unseen by the anesthesiologist who is busy running a perioperative service outside. 

When we talk about an anesthesia care team model, it's usually defined as a team led by a physician anesthesiologist supervising a CRNA. We can call it supervision, but once the patient is inside the operating room, the supervision pretty much stops and the CRNA can do pretty much they please while the physician "leader" is outside keeping the operating schedule flowing smoothly and efficiently. The anesthesia part of the job is very much diminished in the ACT model. At the end of the day, I'm exhausted from running around the OR suites without ever actually intubating or sedating a single patient.

I'm afraid this will lead to more severe problems in the future. Since the physician anesthesiologist is outside running a perioperative service, the surgeons may eventually equate the CRNA that they see in the room as the default anesthesia provider. They're the ones doing the cases and chatting up the surgeons, developing a strong professional rapport. 

While we've had a long history inside our hospital and have strong standing relationships with the surgery department, this won't always be the case as younger anesthesiologists and surgeons start working here. I have nearly two decades of service in our hospital so most of the surgeons know me well. But that is not always going to be true with the younger staff. The new surgeons may only see the CRNA sitting in the room even though the anesthesiologist is theoretically the supervisor in this team model. The new anesthesiologist may never develop a strong relationship with the surgeons. When was the last time you saw a surgeon have a long extended conversation in preop or PACU. They're barely there for five minutes to talk with the patient then they're gone. All the long meaningful conversations take place in the OR, which our younger staff will less of a have a chance to participate in.

Thus the influence of CRNA's will continue to grow in the hospital. It's not because they are any more qualified or more skillful than physician anesthesiologists to give sedation. It is the insidious way that the ACT model pushes the anesthesiologist outside the OR, diminishing their role as the leader in the anesthesia team. Our highly trained abilities to resolving split second complications in the OR will go unappreciated as the surgeons only see the nurses working and appreciating their anesthetic skills, not ours.

Thursday, March 25, 2021

Fear Of The Unknown CRNA

When the anesthesia leadership first announced that we were taking on CRNA's as part of the hospital's deal to rescue the group, they were met with anger and disbelief. "How could they do this to us?" "I'm not spending all day babysitting a bunch of nurses and putting out fires all over the OR's that they will create." "We are doomed and this is just the first crack in the door for the CRNA's to eventually move in and kick us out." The anguish was epic. It felt like a betrayal of the physician anesthesiologist brotherhood that we had fought for so many decades to sustain.

Once cooler heads prevailed, it was clear we were behind the times in developing the anesthesia care team model. There were few large groups of anesthesiologists who didn't use CRNA's. The economic advantages were pretty compelling if one looked at it with a cold unemotional eye. We were also desperately short staffed and it was difficult to hire enough anesthesiologists in the short and long terms to fulfill our hospital's service contract. 

Mainly it was fear of the unknown that caused all this trepidation. Our hospital had never used CRNA's before. Our group has been around for three decades and many of us had never worked with them. Some of the partners who transferred from other groups relayed horror stories they encountered while working with the nurses. Ultimately, none of the excuses we came up with could defer the inevitable. Dollar signs trumped irrational fearmongering. 

We have now been working alongside CRNA's for several months. So far most of them have been excellent. It helped that the first few we hired were real superstars. They each had many years of experience and could be trusted to do the right thing when left alone in the OR. They instilled a lot of confidence from the group and tamped down any murmurings about the qualifications of CRNA's.


Of course, like any group of people, there will always be a few who are not up to snuff. We haven't had anyone yet that I would call bad. However, we've had several who came to us straight out of CRNA training. They are as green as Kermit the Frog's back. Those we put on a shorter leash, more so than new anesthesia residency graduates. 

Speaking of residents, since most of us had not worked with CRNA's in the past, it was a really delicate situation trying to figure out exactly how much independence to give them. We know how to supervise anesthesia residents. We know their education levels and can adjust the oversight based on which year residency they're in. For CRNA's, it was more of a gray area. Yes they are certified and have the proper credentials. But it was hard for us in the beginning not to want to sit in the room with them during the entire case to see if they really know what they're doing. We were told that was too intrusive and we can't treat them like residents. So we just had to learn to trust their judgement and let them do their jobs that they were hired to do. That took a little getting used to.

Another fear of hiring CRNA's that so far has not yet materialized is getting the nurse with an attitude. You know what I'm talking about. These are usually found in public medical facilities like county hospitals or the VA. They are the CRNA's who cop an attitude when we try discussing the anesthetic plan with them. They have an almost militant attitude where they are trying to prove that they are the equal of physician anesthesiologists and constantly trying to put physicians down. These are not team member nurses that would work well in an ACT model. Luckily we haven't hired anybody like that and we're keeping our fingers crossed on not getting one.

So far any adverse events involving our new CRNA's have been few and far between. Of course we don't have too many nurses right now and we're keeping a rather close eye on each one of them. Eventually we'll have to let them have a little more independence. When that happens, I can see how our physician anesthesiology group could become jeopardized by the presence of having CRNA's around. I'll get to that dire prediction next.

Tuesday, March 23, 2021

The Anachronism Of An All Physician Anesthesiologist Practice

 

The all physician anesthesiologist group

 

Prior to becoming hospital employees, our anesthesia group had been fiercely proud of our all physician anesthesiologist makeup. Our group had served our hospital well in this fashion for three decades. Before that, the hospital also had never hired any CRNA's. But that was then. Medical economics has transformed tremendously in the past several decades. It was probably a long time coming but the covid pandemic pushed us into an anesthesia care team (ACT) model and there is no turning back.

First of all, let's set aside the question of equivalency between physician anesthesiologists and CRNA's. That is a contentious discussion that has been well covered in this blog and anesthesia posts all over the internet. Let's just talk about the nitty gritty, the dollars and cents aspect of using CRNA's. While our group was researching the pros and cons of the hospital takeover offer, we discovered that we were one of the last large all physician groups still in existence. Almost every other large anesthesia group had switched to an ACT years, or decades ago. We were an anachronism, a dinosaur. We were the equivalent of an Al Bundy, sitting around thinking about how good we had it years ago and wondering why we don't have it as good as the next door neighbor driving a Mercedes.

If one looks strictly at economic factors, then hands down the use of CRNA's makes perfect sense. You can hire two or three nurses for one anesthesiologist. If the medical facility is expanding rapidly like ours, then it quickly becomes cost prohibitive to hire more anesthesiologists every time new OR's come on line and need to be serviced. The current shortage of anesthesiologists makes this a buyer's market. With the lack of benefits in our old business model, we were having a terrible time trying to get new recruits to consider joining our group. This made our service agreement with the hospital difficult to fulfill as we were frequently short of enough people to cover all the OR's. We were in danger of losing our hospital contract if we couldn't live up to our obligations.

A second impetus for the hospital to switch to a care team model is the ever decreasing anesthesia reimbursements from insurance companies and the government. Every hospital would love to have an all physician anesthesiologist group staffing the operating rooms. Unfortunately the entities paying the bills don't see it that way. They are looking for the least expensive method to achieve the same quality results. While we were desperately holding onto our physician anesthesiologist model, others have figured out that having a physician led ACT was almost as good for a lot less money.

When we saw the overwhelming odds that our anesthesia group was not going to survive through the pandemic and beyond, it almost wasn't a choice anymore. We had a hospital that was willing to keep our group intact and offer us extremely generous benefits we never had before. The only thing in return that they asked for was that we incorporat CRNA's into our practice. We would have committed professional suicide if we turned down their terms due to misplaced pride. The first CRNA joined our group one month after we signed on the dotted line.

Monday, March 22, 2021

There Is No Perfect Job

When we switched from an independent contractor to an employee job model, a huge weight was lifted off our shoulders. The constant threat of insurance and Medicare reimbursement cuts no longer fell directly on the group. The fluctuating caseloads in the OR during a pandemic made less of an impact on our individual incomes. We thought we had found the formula for the perfect job.

Going in, we weren't just wearing rose-colored glasses. We knew that employed physicians typically made less money than fee for service. This is borne out every year in Medscape's physician compensation survey. But the picture is more complicated than a simple graph.

As independent contractors, we worked as much or as little as we wanted. Some people who wanted a large income could slave away every night and weekend to make a ton of money, far higher than the average anesthesiologist's income in the survey. Others desired more free time and worked less, making much less than the survey average. But those were the choices each individual made for themselves. Now that is no longer an option.

The hospital is paying each of us for a contractually determined number of working hours per day. The ability to leave early because you feel like going outside to absorb some of that bright California sunshine is not permissible. If you finish your OR lineup early, they'll find other cases for you to do until you've fulfilled your work hours for the day. You can't just walk out and refuse to do more work. You're an employee now with expectations of how an employee needs to behave in a workplace. If there really is no other cases in the OR pending, then you can be dismissed early, but that is a rarity.

The flip side is that somebody who wants to work longer hours to make more money also can't do that. After you've filled your quota of hours for the day, they almost push you out the door so they don't have to pay overtime. Therefore your income ceiling is much lower than before. Everybody's income in the department has narrowed closer to parity.

This loss of individual choice was very difficult to adjust to and I've yet to fully come to grips with it myself. When doctors say they don't want to lose their independence, this is what they mean. Suddenly people are telling you when and how you can work.

I've also noticed a new psychology at work that I never experienced before when I was working for myself. I was often amused before about how nurses frequently say they only have another so many hours or minutes to go before the end of their shift. I thought to myself how nice it was that there is a definite end to their workday. After we switched over, I started behaving the same way. When they want to add another case to my room late in the afternoon, I no longer get riled up about it. I just look at the clock to see how close to finishing I am and thank my lucky stars I'm not the one who will be stuck doing this five hour spine case the rest of the night.  

Those aren't even the biggest changes we've experienced since becoming hospital employees. The more predictable daily hours and generous benefits are wonderful. However there's a price for all this largess; the hospital expects something in return for taking us in and providing these benefits.

Suddenly hiring a large number of anesthesiologists added a huge chunk of money to their payroll expenses. In order for it to work out economically, the hospital decided that they wanted to move to an anesthesia care team model. In other words, we now work with CRNA's. And that, my MD/DO anesthesia friends, has been an eye opener.

Sunday, March 21, 2021

From 1099 To W-2 in 2020


Overnight, we morphed from independent contractors to hospital employees as the hospital took over our anesthesiology department. I won't go over again all the details about why our group made the switch, but it was done out of necessity due to the pandemic and the reality of a different set of expectations among younger physicians.

This change brought on many immediate improvements. No longer was there an obligation to work late into the night if the room was running long. If you weren't on call, they almost hustled you out of the OR by 5:00 PM lest the hospital had to pay overtime. Working weekends brought extra pay. The set work hours was a revelation for those of us who had only known unpredictability and exhaustion. My wife even remarked that sometimes it felt like I was only working part time when I kept coming home before the children went to bed. 

Besides having a set number of hours per day, we also finally achieved a contractually determined number of vacation and sick days. As independent contractors, we could theoretically determine our own work hours and take as many vacation days as we wanted. But if we did that, we won't make any money and it's no fun losing your house because you wanted to take a month long vacation to explore the world. Now we have paid vacation days and the mental relief of not worrying about paying our bills while taking time off.

Perhaps the most important benefit we received was health insurance. As independent contractors, we had to buy our own health insurance. This flexibility is nice if you're single with no family obligations. But most of us had to worry about family coverage and Covered California, our state's version of Obamacare, was raising its premiums every year while increasing the deductibles and copay. This took a giant chunk out of our monthly incomes. It became my second largest personal expense, after the mortgage on my house. The deductibles for a family reached over $20,000. We weren't even buying the gold plan, but the least expensive plan we could find that included our family doctors in the network. This was essentially a catastrophic health insurance plan which we avoided using as much as possible. We paid almost everything out of pocket as we never got close to using up all the deductible in one year. Now we have much better health insurance from the hospital. It also eliminated a giant hangup to recruiting new physicians as most young people expect to receive their health insurance from work.

The headaches of running a medical corporation also disappeared. No longer did we have to pay the expenses of a large back office operation. The hospital now was in charge of all the billings and collections. No longer were our incomes held hostage by how successful our collections process was. That was the hospital's responsibility to collect the money, not ours. We got paid based on our hospital contract, not how much reimbursement we could achieve.

Having the heft of a hospital behind us also did wonders for insurance company negotiations. Tales are rife of insurance companies unilaterally cancelling their contracts with anesthesia groups, or cutting previously agreed to reimbursement rates. A hospital will have more leverage negotiating with insurance companies than a little single specialty medical group could.

The advantages of becoming hospital employees became evident when California experienced its surge of coronavirus cases last winter. We again had to reduce the OR schedule as the hospital was trying to preserve as much ICU and regular hospital beds as possible. Unlike the first surge though, our incomes didn't change. The hospital continued to pay us as if we were working full time even though many of us were given paid time off for lack of cases. We anesthesiologists were no longer beholden to the surgeons and their operating schedule.

But I shouldn't make it sound like it's all been wine and roses since we became employees. There have also been deep grumblings within the department about some of the changes the hospital has made to our practice. That will be the next installment of this journey.

Saturday, March 20, 2021

Fee For Service Is Over

The Covid pandemic destroyed countless lives and businesses. Our anesthesia group was unfortunately one of its victims. After almost 30 years of independent practice, we decided that the way we conducted business was no longer tenable. It has been a long time coming but Covid gave our group a final shove into the dustbin of history.

The group was an all physician anesthesiologist endeavor. When times were good, they were very good. It was an old fashioned fee for service practice. Some of us who wanted to make more money could work harder and longer than those who didn't want as much income. Some people made money to buy fancy cars and real estate while others earned just enough to satisfy their vacation splurges. Covid put into sharp relief the shortcomings of this model.

When the economy was put into mandatory lockdown by the government, suddenly the economics didn't work anymore. No work meant no money. Most of us were really hurt economically when our incomes dropped well over 50% last spring. Almost all of us applied for the PPP loans, which we qualified for since we were considered independent contractors. Unfortunately the loans were only a temporary bandaid since we can't live on government loans for long. Luckily the lockdowns started to lift just when the PPP loan money was running out. 

Meanwhile the doctors and nurses who were employed by the hospital didn't see any cuts in their incomes, even though they too were working less (other than the pulmonary, ED, ICU, and other so called frontline workers of the pandemic). When the second surge started to hit and our surgical volume waned again, we knew that our anesthesia group needed substantial help. 

In reality, our fee for service model was terribly outdated and could not survive for much longer. There were lots of problems with a business model that had been stagnant for decades. The most pressing issue was the difficulty we had in recruiting. We had survived by hiring people who really wanted to live in Southern California. That was the number one draw. Though the cost of living was exorbitant, some people were willing to take that economic hit to live here. Over the years, as the taxes and housing costs kept rising, fewer people were willing to make that sacrifice. 

The fee for service model also did not appeal to a new generation of anesthesiologists. Yes you can make fist loads of money if you work hard enough. But younger doctors were more interested in a better work-life balance. They were willing to make less if they could be guaranteed set work hours and regular time off to spend at home with their families. We just couldn't do that with our practice. People were expected to stay until all the cases in their room were finished. It was very difficult to plan any family events as there was no way to know even 24 hours ahead what time you might be able to go home. That was a gigantic turnoff to many young doctors.

Then there was the rising cost of doing business. Our back office was taking a substantial portion of the group's income. There was staff to hire, offices to rent, computers systems that needed constant updating as insurance companies and government bureaucrats kept changing how and what kind of paperwork they needed before we could get reimbursement. It was a constant battle to keep expenses down.

I'm not sure who approached who first, but when the hospital saw the difficulties we were having, they proposed to absorb our group into their system. They valued our expertise as we were active in a substantial portion of medical care. Everything from labor and delivery, surgery, critical care, chronic pain, and many other areas of patient management involved our anesthesia training and the hospital was grateful for it. Therefore they couldn't afford for our anesthesia group to suddenly disintegrate and leave them with an unstable and unpredictable anesthesiology department. I can't say it was a buyout as none of us got a buyout offer. Instead, we became employees of the hospital.

Friday, March 19, 2021

Covid Arrived And My Anesthesia Group Died

Hard to believe that it has been a year since the arrival of Covid in the United States. It has wreaked devastation across the landscape, both economically and personally. Millions of people lost their jobs. Millions more got sick and hundreds of thousands have died. 

It's been twelve months since I've lamented that I dropped out of the LA Marathon that ran on March 8, 2020. At the time, the CDC, Dr. Fauci, and plenty of so called "experts" commented that covid will be no worse than the seasonal flu. How wrong we were then. The devastation was just beginning. 

Little did I know that part of the destruction would visit me on a professional level. At the beginning of 2020, our operating rooms were still running like gangbusters. Our surgical volume was set for another record year. Seemed like it was shaping up to be another very prosperous year for our anesthesia group with plenty of bonuses to go around by December. Then everything stopped.

The government ordered all nonessential businesses to shut down for an indeterminate length of time. That included most of our elective surgeries. Basically any cases not involving cancer or life and death situations were cancelled. Our OR cases dropped by more than 50%. Everybody in the group suddenly became underemployed, working one or two days per week. Our income likewise plummeted to heretofore unthinkable levels. Who knew how long this was going to last.

Reprieve granted April 22
Then in late spring, California's Governor Newsom declared that hospitals can start opening up again as the first surge of the coronavirus started to abate. Slowly the operating rooms got busier. But it couldn't get as busy as it was prior to the pandemic as multiple safety protocols were put in place. Getting every single patient tested for covid prior to surgery proved extremely challenging. Rules for proper testing were fluid and ever changing. But we struggled through the summer as the hospital eventually developed a new pattern of normalcy.

But by early fall, there appeared to be another surge starting to form and our volume dropped again. This was starting to get very scary for every anesthesiologist in the group. We could not maintain our livelihoods based on the vagaries of the action of a virus. What if a vaccine doesn't get developed for years? What happens if many of us with large student loan debts and new mortgages to pay are pushed into insolvency? There seemed to be only one way out of this quagmire. And the answer was something we were determined never to do until we had to do it--we abandoned our medical group and joined with our hospital as employees.