Metaphor for employed jobs vs ...

[nexus73]

I am an employed psychiatrist. I was considering that it is like something to be in this job, different than private practice, locums, various 1099 jobs, etc. Being employed I have bosses, one or two are physicians, plus a bunch of non-physicians. Some of the non-physician "bosses" are actually super helpful, like coders who tell me I've overbilled or underbilled, or how I can optimize my note for billing. Some bosses don't know anything about psychiatry (my physician bosses are not psychaitrists) but are still in charge. I sometimes have conflict with bosses or with other departments and the bosses function as mediators to some degree.

Anyhow, I was talking to a co-worker and we were, as often happens, complaining about various problems at our employed job. Not enough docs, too much call, bad consults from medicine, administrators who don't know anything, etc etc. Clearly, this is not very productive but helps us feel better.

Trying to stay more positive I recounted what I'm grateful for at this job, which is a lot of things truly. I started thinking being employed as a metaphor (or simile) is like trading in your noble title at the feudal manor, where you are mostly in charge, in exchange for a place in the king's knights. Being in charge at the manor carries a lot of perks, but it's a more meager existence, and you still aren't full in charge really, there are lords above you in the line up to the king. As a knight in service to the king, you trade the independence and control, but get to live in the 'big city' with all the amenities, you would get paid a good wage, have access to better food likely, potentially security, but you don't have a manor to for anyone to take at that point, but essentially you've signed up to do the king's bidding day in and day out. At the manor, there are still people higher up you would answer to, but most of the time you're running things how you see fit.

How much leverage does a knight or group of knights have over the king?

How much leverage does the nobleman at the manor or coalition of nobleman have over the king?

The king in this sense, represents hospital administrators or the hospital in general, and in some ways the government bodies that regulate medicine.

Is it better to live a more meager existence, with potentially less security than to trade it in for a place with the king?

Locums are like the sell swords charging high wages for the cause du'jour.

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[Bartelby]

Employed psychiatrists are knights in the King's court and private practice are the Free Folk. You are out in the cold with no one to give you direction but you build something totally your own.

 

[dl2dp2]

I don't think your comparison here is apt. In this particular line of work, the most desirable jobs are outside of large hospital systems that involve equity ownership, and there's no further "king" to answer to.

There are some risks for private practice or locum, but the risks are very minor. And in terms of "existence", the earnings is generally much HIGHER outside the hospital systems. Sure, the variance is higher, but it's not THAT high if you are willing to be flexible to start.

In some specialties, hospitals act as useful conduits for high-value clinical services (i.e. transplants, etc), and living off the king is more materially protective than making attempt to open your own shop. In psychiatry, this is simply not the case.

Now in specific locations, this might be the case, like if you are in a smallish metro where the single nonprofit hospital basically dominates the local payers and no self-pay demographic exists, but by and large, the dynamic is not as described. I'm familiar with several large academic medical centers, and everyone tells me that their department loses millions a year and gets subsidized by subspecialty surgery. This is not exactly "better food". The prevailing narrative is that employed psychiatrists take a pay CUT because of some higher calling (payer mix, service, education, etc). They are the ones who typically complain of "meager existence". It's actually very problematic because academic salaries are not increasing much if at all last two years despite crazy inflation.

 

[forchinet121]

I don't think your comparison here is apt. In this particular line of work, the most desirable jobs are outside of large hospital systems that involve equity ownership, and there's no further "king" to answer to.

There are some risks for private practice or locum, but the risks are very minor. And in terms of "existence", the earnings is generally much HIGHER outside the hospital systems. Sure, the variance is higher, but it's not THAT high if you are willing to be flexible to start.

In some specialties, hospitals act as useful conduits for high-value clinical services (i.e. transplants, etc), and living off the king is more materially protective than making attempt to open your own shop. In psychiatry, this is simply not the case.

Now in specific locations, this might be the case, like if you are in a smallish metro where the single nonprofit hospital basically dominates the local payers and no self-pay demographic exists, but by and large, the dynamic is not as described. I'm familiar with several large academic medical centers, and everyone tells me that their department loses millions a year and gets subsidized by subspecialty surgery. This is not exactly "better food". The prevailing narrative is that employed psychiatrists take a pay CUT because of some higher calling (payer mix, service, education, etc). They are the ones who typically complain of "meager existence". It's actually very problematic because academic salaries are not increasing much if at all last two years despite crazy inflation.

You keep talking about equity ownership, by that do you mean a practice that hires NPs and other providers then profits of them and you have equity of that profit?

 

[dl2dp2]

You keep talking about equity ownership, by that do you mean a practice that hires NPs and other providers then profits of them and you have equity of that profit?

No. I own my practice but I do not hire NPs.

Hired labor might have equity value, they might not and be strict liability. Owning equity means that you have some ownership stake in the business entity within which you operate. It has nothing to do with exactly how the business is operated.

The reason that the most desirable jobs involve equity ownership is that when you own [controlling] equity, you can't really be fired. If you can't be fired, there's no boss to answer to. If there's no boss to answer to, you can't be exploited. This implies that your total compensation equals to exactly the market value of the services and goods you deliver subtract from overhead spending. A "boss" is a middleman--as the OP said, a boss is a "mediator" of some sort. When you remove the boss the ins and outs become cleaner.

The above-average psychiatrist has an above-average value in the market but is not profiting from that value because this value is the proverbial "excess value" that gets extracted by the employer. This aspect has nothing to do with whether you hire people.

A job has an illusion of security prepackaged. Ultimately jobs are nothing more than a line item of cost. True security involves control of CAPITAL. Many physicians get fired and replaced by NPs and at random times outside of their control. Many MANY physicians had to leave their jobs at the wrong time because of a "bad boss". These are all risks people don't think about when they get fixated on how having a job is "safer" than starting a business.

 

[the5thelement]

And the leeches and parasites which insert themselves between the patient and doctor are relentless in their pursuit of the almighty dollar. They have managed to create the beautiful illusion of security in employment.

 

[When is graduation again?]

No. I own my practice but I do not hire NPs.

Hired labor might have equity value, they might not and be strict liability. Owning equity means that you have some ownership stake in the business entity within which you operate. It has nothing to do with exactly how the business is operated.

The reason that the most desirable jobs involve equity ownership is that when you own [controlling] equity, you can't really be fired. If you can't be fired, there's no boss to answer to. If there's no boss to answer to, you can't be exploited. This implies that your total compensation equals to exactly the market value of the services and goods you deliver subtract from overhead spending. A "boss" is a middleman--as the OP said, a boss is a "mediator" of some sort. When you remove the boss the ins and outs become cleaner.

The above-average psychiatrist has an above-average value in the market but is not profiting from that value because this value is the proverbial "excess value" that gets extracted by the employer. This aspect has nothing to do with whether you hire people.

A job has an illusion of security prepackaged. Ultimately jobs are nothing more than a line item of cost. True security involves control of CAPITAL. Many physicians get fired and replaced by NPs and at random times outside of their control. Many MANY physicians had to leave their jobs at the wrong time because of a "bad boss". These are all risks people don't think about when they get fixated on how having a job is "safer" than starting a business.

These are all really valid points. I'll add that private practice also allows you bypass really complex, inefficient, and overbearing systems that add external stress to our roles. I work as a 1099 in a community setting that had a terrible time getting quality physicians before I showed up plus I focus on financial independence, so I'm not beholden to my job. My job also can't replace me with an NP due to regulations on our service model. The king doesn't bother me, so I don't have annoyances from above.

I do, however, deal with one of the worst pharmacy partners imaginable (I'm working on rectifying this), DOJ complaints when we don't take their clearly antisocial referrals, long phone wait times getting Medicaid to continue meds keeping people stable, and having to hear about b.s. office politics (I'm kept out of it mercifully), among a slew of a thousand other cuts. If it wasn't for my love of my patient population, I definitely would've went private. I still might in a year or two.

 

[clausewitz2]

Slight misunderstanding of feudalism here, at least if we are talking about classic Northwestern European type fedualism. Knights would not be answering to anyone at a manor house because they would be in charge of a manor house. Knights were defined as holding a significant amount of property in fief from their liege, theoretically being sufficient to generate the revenue to pay for their arms/armor/horses/etc. They would also bring their own dedicated retinues to war with them when called upon.

If the noble analogy is being pursued instead, if the question is 'how much power did a coalition of nobles have over the king?', the answer varies, but often between 'quite a lot' and 'total'. In some contexts (11th century France) the king was effectively powerless compared to his over-mighty vassals. Without getting too into the weeds, the Magna Carta and the existence of parliaments are both the direct results of monarchs being reined in by their vassals.

Agree the locums are foreign mercenaries.

If we want to stick with Western Europe, we have to go earlier, back to before the concept of knights existed. Closer parallel is probably the class of tribal warriors described in Beowulf or the Tain, living in the hall of their lord/ringer-giver, feasting at their table, sleeping in their hall, and wearing gaudy jewelery (armbands, torcs, etc) as a mark of their station and favor. If they decided to desert someone en masse it would be a problem but individually they would have had minimal influence over their patron. That is closet to employed psychiatrists; rewarded and valuable but replaceable and not consulted for major decisions, kept for their utility.

Really best parallel in the period is the Eastern Roman Empire (aka Byzantine) and the relationship between the magnates and the imperial court. You might have very distinguished and prominent notables given all kinds of fancy-sounding titles that mean very little practically but form an elaborate hierarchy. At the end of the day you would still be coming to the palace once a year to line up in public, in order of precedence according to your ceremonial rank, to wait for hours until it was your turn to be handed a sack of gold by a palace official that would constitute your annual salary, just so there was no mistaking who buttered your bread.

Also if something goes wrong it's going to be you tonsured and forced into a monastery/convent or blinded/mutilated and banished to an island in the middle of nowhere.

 

[forchinet121]

Slight misunderstanding of feudalism here, at least if we are talking about classic Northwestern European type fedualism. Knights would not be answering to anyone at a manor house because they would be in charge of a manor house. Knights were defined as holding a significant amount of property in fief from their liege, theoretically being sufficient to generate the revenue to pay for their arms/armor/horses/etc. They would also bring their own dedicated retinues to war with them when called upon.

If the noble analogy is being pursued instead, if the question is 'how much power did a coalition of nobles have over the king?', the answer varies, but often between 'quite a lot' and 'total'. In some contexts (11th century France) the king was effectively powerless compared to his over-mighty vassals. Without getting too into the weeds, the Magna Carta and the existence of parliaments are both the direct results of monarchs being reined in by their vassals.

Agree the locums are foreign mercenaries.

If we want to stick with Western Europe, we have to go earlier, back to before the concept of knights existed. Closer parallel is probably the class of tribal warriors described in Beowulf or the Tain, living in the hall of their lord/ringer-giver, feasting at their table, sleeping in their hall, and wearing gaudy jewelery (armbands, torcs, etc) as a mark of their station and favor. If they decided to desert someone en masse it would be a problem but individually they would have had minimal influence over their patron. That is closet to employed psychiatrists; rewarded and valuable but replaceable and not consulted for major decisions, kept for their utility.

Really best parallel in the period is the Eastern Roman Empire (aka Byzantine) and the relationship between the magnates and the imperial court. You might have very distinguished and prominent notables given all kinds of fancy-sounding titles that mean very little practically but form an elaborate hierarchy. At the end of the day you would still be coming to the palace once a year to line up in public, in order of precedence according to your ceremonial rank, to wait for hours until it was your turn to be handed a sack of gold by a palace official that would constitute your annual salary, just so there was no mistaking who buttered your bread.

Also if something goes wrong it's going to be you tonsured and forced into a monastery/convent or blinded/mutilated and banished to an island in the middle of nowhere.

Why/how do you know all of this

 

[finalpsychyear]

I am battling this situation currently. I have a 1.5 day wk/pp while being a 1099 for a tele/hybrid clinic. Recently, due to the scale back of the med dir at clinic I was offered the spot. Later found out i couldn't be 1099 due to hierarchy and have that title etc. Also the benefits are crap as I declined their health benefits. I felt pressured as if i didn't accept, in my mind they were logically going to look for someone else and possibly be in a situation where they would find some new naive doc to not only take it but also supervise many NPs for a low ball number then i may be axed.

I have since been more proactive about growing my PP

 

[clausewitz2]

I am battling this situation currently. I have a 1.5 day wk/pp while being a 1099 for a tele/hybrid clinic. Recently, due to the scale back of the med dir at clinic I was offered the spot. Later found out i couldn't be 1099 due to hierarchy and have that title etc. Also the benefits are crap as I declined their health benefits. I felt pressured as if i didn't accept, in my mind they were logically going to look for someone else and possibly be in a situation where they would find some new naive doc to not only take it but also supervise many NPs for a low ball number then i may be axed.

I have since been more proactive about growing my PP

That sucks, not least because being offered employer sponsored health benefits and declining them has implications for the tax deductible status of any health insurance premiums you are paying on your own as a self-employed person.

 

[Candidate2017]

Nah, just like medieval times, 98% of the labor are serfs or peasants. Serfs are tied to the land, while peasants aren't. Employed docs are more like serfs. If your employer sells the hospital/clinic/land, they are selling you as well, and you will likely stay and continue to hoe that piece of land/hospital/clinic rather than promote yourself to peasant and move on to hoe someone else's land. Either way, keep on hoe'ing.

 

[finalpsychyear]

That sucks, not least because being offered employer sponsored health benefits and declining them has implications for the tax deductible status of any health insurance premiums you are paying on your own as a self-employed person.

True. However, technically lets says i had stayed 1099. If my spouse is in any way able to get subsidized health insurance ever i would still not be able to deduct this so i am not sure how often people know that part. Also, if you "miss" open enrollment not sure that qualifies as declining.

Does 1099 and w2 dual status effect anything else such as any other business deductions like suv over 6000 pounds etc? Still super annoyed about this situation. I havent signed the dotted line but not sure if its worth pushing back on.

 

[annoyedpsychiatrist]

I work for a hospital system and I like my job so far. There really isnt anything I can fault them for so far. They seem to be making a lot of via grants and all that stuff so they dont seem as rvu driven as regular private practice jobs. When I interviewed at private practices a while ago, they all seemed like the motto was schedule as many patients as possible for zoloft and adderall refills and shoot for 25-30 pts a day