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By: Greg Caesar

In the ever-evolving healthcare landscape, private practice surgeons are navigating significant transformations in employment models. The shift from independent practice to hospital employment or integration into large group practices marks a pivotal change in how surgeons manage their careers and practice medicine. This transition, influenced by the consolidation of healthcare systems and the growing influence of private equity in healthcare, has profound implications for practice management, private practice surgeons, and the broader surgical community. These changes are reshaping the terrain of the medical profession, demanding a nuanced understanding of their impact on both surgeons and patient care alike3.

There are multiple facets of the new employment models, including the regulatory, legal, and financial considerations that come into play. Additionally, it is important to understand how surgeons and their practices are adapting to new technology, additional administrative responsibilities, and the implications for patient care and quality. The future includes the changing landscape of surgical practices, focusing on professional autonomy, work-life balance, and the challenges and opportunities that lie ahead for private practice surgeons. Continue reading to gain insights into the complex dynamics of practice management and the evolving role of surgeons within the healthcare ecosystem345.

The Shift from Private Practice to Hospital Employment

Rising Operational Costs for Surgeons in Private Practice

The financial landscape for private practices has grown increasingly challenging over the past 15 years due to operational costs significantly outpacing revenue. Notably, the median loss per physician for system-affiliated groups has reached over $249,000, highlighting the widening gap between income and expenses14. This financial strain is exacerbated by external factors such as rising labor costs, labor market shortages, and regulatory changes14. Additionally, medical practices have seen their overhead costs, which can range between 60% and 70% of their revenue, steadily increase due to necessary expenses like staff health insurance premiums, administrative requirements, and medical technology15.

Increasing Hospital Acquisitions of Private Practices

In recent years, there has been a notable surge in hospital acquisitions of private practices. Between 2019 and 2021, hospitals and other corporate entities acquired over 20,900 physician practices, a significant increase that was further accelerated by the COVID-19 pandemic6. This trend reflects a broader shift in the healthcare landscape, where nearly three-quarters of physicians are now employed by hospitals, health systems, or other corporate entities17. The growing rate of these acquisitions underscores the challenges faced by independent physicians, who often struggle with the financial and administrative burdens of maintaining a private practice17.

The Appeal of Hospital Employment for Surgeons

Hospital employment offers numerous advantages that are increasingly attracting surgeons away from private practices. Many surgeons appreciate the financial security and the ability to focus more on patient care rather than the administrative aspects of running a practice18. Hospitals often provide a steady salary and absorb the costs of medical equipment and malpractice insurance, which in some specialties physicians are finding these to be prohibitively expensive for private practices 18. Furthermore, hospital-employed surgeons benefit from a structured environment where administrative tasks are handled by professional staff, allowing them to concentrate on clinical duties and patient interaction18. This shift is particularly appealing to younger surgeons who prioritize work-life balance and opportunities for career advancement within well-established healthcare systems18.

The Rise of Private Equity in Healthcare

Understanding Private Equity Investment in Healthcare

Private equity (PE) firms have significantly increased their investments in the U.S. healthcare sector, pouring over $206 billion into various initiatives in 2021 alone. This surge includes funding for research, facility expansion, and modernization of medical records33. In recent years, there has been a notable spike in PE acquisitions of surgical practices, with more than 250 investment deals completed in outpatient clinics in 2020, particularly in high-demand areas like dermatology, where PE firms now own more than 10% of the market33.

The Impact on Private Practice Surgeons

The infusion of private equity in healthcare can bring substantial benefits to private practice surgeons. These investments often provide the capital needed to enhance healthcare delivery, expand surgical services, and acquire advanced medical equipment. For instance, PE firms invest in technologies that improve surgical scheduling and automate manual procedures, which can significantly upgrade practice operations without the financial stress on practice owners33. However, the extent of control retained by PE firms can vary, sometimes leading to practice owners feeling they have lost influence over the practices they built, especially if business-driven decisions prioritize profitability over comprehensive patient care33.

Benefits and Drawbacks for Surgeons

The relationship between private practice surgeons and private equity firms can be complex. On one hand, PE investments bring seasoned business professionals into practices, helping them become more efficient and profitable. This often includes cutting costs and optimizing procedures with the goal of selling the practice for profit within a few years33. On the other hand, this model can lead to conflicts, as the short-term investment focus of PE firms may prioritize immediate financial gains over the long-term sustainability of the practice, potentially leading to a loss of physician autonomy32.

Surgeons must weigh these factors carefully. The potential for rapid practice expansion and professional management can be attractive, but the loss of control and the pressure to meet financial metrics set by PE investors can detract from the quality of patient care and professional satisfaction32. Additionally, the high turnover of practices among PE firms can disrupt continuity and may not align with the long-term health outcomes desired by medical professionals33. However, PE investors often bring a litany of business operations experts in to support their investment. As stated before, the growing burden of administrative responsibilities does not look to be something that will go away in the near-term, further influencing the decision of many private practice owners to accept PE offers.

Regulatory and Legal Impacts

Changes in Healthcare Legislation

The healthcare landscape has seen transformative legislative changes aimed at enhancing the quality and accessibility of medical services. Notably, the Affordable Care Act (ACA) expanded coverage to millions by introducing health insurance exchanges and subsidies, emphasizing preventive care and aiming to reduce healthcare access inequalities46. Similarly, the Medicare Access and CHIP Reauthorization Act (MACRA) shifted the focus from volume-based to value-based care, incentivizing providers through the Quality Payment Program (QPP)46.

Further regulatory scrutiny has been directed towards the safety and quality of surgical care. Agencies like the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission have implemented new quality improvement initiatives and reporting requirements to promote transparency and improve patient outcomes. Non-compliance with these standards could lead to significant penalties or loss of accreditation for surgical practices46.

Antitrust Concerns with Hospital and Private Equity Acquisitions

Recent years have witnessed heightened antitrust scrutiny, particularly concerning the influence of private equity (PE) and hospital acquisitions in the healthcare sector. The Federal Trade Commission (FTC), Department of Justice (DOJ), and Health and Human Services (HHS) have been actively seeking information on the effects of healthcare transactions through Requests for Information (RFIs) and workshops5253. These efforts aim to understand and potentially regulate transactions that might commoditize healthcare, prioritizing profits over patient health and care quality5253.

Particularly concerning are the practices of “strip and flip” and “roll-up” transactions by PE firms, which involve acquiring healthcare providers and rapidly reselling them for profit, often bypassing traditional antitrust reviews54. Additionally, the presence of interlocking directorates, where board members serve across competing firms, has raised alarms about potential conflicts of interest and anticompetitive behaviors5253.

At the state level, there is a surge in legislation targeting these acquisitions. States like California are now requiring PE firms to receive approval before acquiring healthcare facilities, with nearly 20 states adopting enhanced notification requirements similar to the Hart-Scott-Rodino Act to foster transparency and prevent anticompetitive practices5254.

These regulatory and legal frameworks are crucial in ensuring that healthcare mergers and acquisitions do not undermine patient care quality or inflate healthcare costs, thereby maintaining a competitive and fair healthcare market.

Financial Considerations

Compensation Models for Surgeons

Understanding the various compensation models is crucial for surgeons as they navigate their career options in either private practice or hospital employment. Compensation structures have evolved to include simpler formats such as straight salary or base salary plus bonuses, which are common in large HMOs and academic settings56. These models often provide a predictable income, but may lack long-term financial incentives if there is no ownership track, potentially discouraging entrepreneurship56.

Alternatively, production-based compensation models link pay to the physician’s productivity, measured through billings, collections, or relative value units (RVUs). Although this model can incentivize additional effort, it may also foster a competitive environment that could detract from collaborative patient care56. Capitation models, which pay a set amount per patient, reward cost-efficiency but depend heavily on market conditions and negotiation skills, which can lead to fluctuating income levels56.

Value-based care models are increasingly prevalent, tying compensation to the achievement of specific performance metrics that emphasize quality and cost-efficiency63. This approach aligns physician incentives with patient outcomes, fostering a healthcare environment focused on quality rather than quantity.

Cost-Benefit Analysis of Private Practice vs. Hospital Employment

When comparing the financial implications of private practice versus hospital employment, several factors come into play. Private practice offers autonomy and the potential for higher earnings but comes with significant financial risks and responsibilities, such as managing staff and overhead costs62. Surgeons in private practice must also navigate the complexities of billing and insurance reimbursements, which can affect income stability62.

Hospital employment, by contrast, provides more predictable earnings and relieves physicians from many administrative burdens. Hospitals typically handle billing, collections, and other administrative functions, allowing surgeons to focus more on patient care62. However, this model may offer less autonomy and could limit earning potential compared to owning a private practice, where well-managed practices can achieve significant financial success62.

Decisions between these models often depend on individual preferences for risk, financial goals, and professional autonomy. Younger surgeons or those less inclined towards business management may find hospital employment more appealing, while more entrepreneurial physicians might prefer the control and potential upside of private practice62.

Adapting to New Technology and Administrative Responsibilities while Practicing Full-time

Technological Advancements in Surgical Practices

In the realm of surgical practices, the integration of cutting-edge technologies has been pivotal. Innovations such as optical imaging, robotics, and advanced computational methods are enhancing surgical precision and reducing invasiveness66. The development of the MARVEL tool, a 3-D high-definition endoscope, exemplifies how technology is refining tumor resection procedures by providing surgeons with precise 3-D visualizations66. Similarly, the evolution of smart glasses and robotic assistants illustrates the shift towards mixed reality methods and AI-enhanced surgeries, which support surgeons in performing complex procedures with heightened accuracy and efficiency6667.

Robotics, along with other less-invasive approaches to surgery, have transcended traditional surgical boundaries, offering solutions for patients which previously were only accessible in specialty hospitals. Today robotics are more prevalent and which significantly mitigate human limitations70. The integration of AI with robotic systems is set to revolutionize surgical practices by minimizing errors and optimizing procedural outcomes, thus highlighting a future where technology and human expertise coalesce to enhance patient care70.

The Burden of Administrative Tasks

The administrative load on healthcare providers has escalated, becoming a major source of frustration and inefficiency. Physicians report spending extensive hours on paperwork, significantly detracting from patient care time7172. Studies have shown that doctors might spend up to two additional hours daily on electronic health records (EHR) and other administrative duties, which could extend into after-hours work at home7374. This excessive administrative burden is not only a logistical challenge but also a significant contributor to physician burnout, with many healthcare professionals citing it as a primary stressor74.

The disparity in administrative load is also evident across different demographics and practice settings. For instance, female physicians report a higher percentage of after-hours work, which may affect their long-term career satisfaction and retention75. Furthermore, community health centers face unique challenges due to stringent reporting requirements, which can detract from direct patient interactions and increase stress among healthcare providers75.

Efforts to mitigate these burdens include the adoption of Artificial Intelligence as well as process automation or the use of scribes. These interventions have been shown to reduce time spent on EHR documentation and improve overall job satisfaction74. However, as the healthcare landscape evolves towards value-based care models, the necessity for detailed reporting and quality metrics will likely perpetuate the administrative demands on physicians and further stress care-oriented providers74.

Patient Care and Quality Implications

Effects on Patient-Doctor Relationships

The quality of patient care is profoundly influenced by the personal well-being of physicians, as adverse impacts on physicians’ personal relationships are significantly associated with unsolicited patient complaints, a robust indicator of patient care quality77. These complaints can be linked to malpractice risks and also to adverse clinical outcomes, underscoring the importance of organizational efforts to foster environments that support physician well-being and, consequently, enhance patient care77.

Mentors within the medical community play a crucial role in shaping the patient-doctor relationship. Positive role models, who exhibit enthusiasm, empathy, and effective communication skills, significantly influence medical students and young doctors, guiding them towards specialties that best suit the student’s skills, temperament and passion. These role models not only demonstrate holistic care but also support the development of essential interpersonal skills which are critical in nurturing positive patient-doctor interactions78.

Conversely, exposure to negative role models, who may exhibit poor communication or prejudiced behaviors, can deter aspiring physicians from certain specialties and negatively impact their approach to patient care78. This highlights the dual impact of role modeling on both career choices and the quality of patient interactions in various healthcare settings.

Quality of Care in Different Practice Settings

The setting in which physicians operate—whether in private practice or hospital employment—significantly affects the quality of care delivered. In hospital settings, physicians often benefit from structured environments that handle administrative tasks, allowing them to focus more on patient care. This can lead to enhanced patient outcomes due to reduced distractions from non-clinical responsibilities8183. Hospitals also provide a steady flow of patients and more predictable work schedules, which can contribute to better managed and more focused patient care8183.

In contrast, private practice offers physicians autonomy over their work environment and patient interactions. This independence can lead to highly personalized care but also requires doctors to manage administrative duties, which can detract from time spent with patients8184. However, for those who thrive in an autonomous environment, private practice can offer the flexibility to innovate and tailor care to patient needs more directly, potentially enhancing patient satisfaction and outcomes84.

The choice between these settings can influence not only the lifestyle and job satisfaction of physicians but also the quality and personalization of care received by patients. Thus, organizations and physicians must carefully consider how the work environment will impact not only operational efficiency but also patient care quality and physician well-being8184.

The Future Landscape of Surgical Practices

Predictions for Private Practice Survival

The landscape of private practice in surgery is undergoing significant transformations. According to recent trends, the number of surgeons in private practice is declining, with a notable shift towards employment within larger health systems or private equity groups. From 2012 to 2022, there was a 13% decrease in surgeons working independently, reflecting a broader movement towards more structured healthcare environments86. This shift is largely driven by financial pressures, including changes in reimbursement models and increased regulatory demands, which make sustaining an independent practice increasingly challenging86. Despite these trends, some experts believe that private practice will persist, albeit in a different form, potentially dominated by large specialty groups or those integrated with major health systems86.

Evolving Business Models for Surgeons

In response to the changing dynamics, new business models for surgical practices are emerging. These models are designed to address the financial and administrative burdens that have historically plagued private practices while enhancing the quality of care. For instance, the integration of technology and data analytics is seen as a crucial strategy for improving efficiency and patient outcomes92 . However, critics of cite the additional administrative burden of compiling this data takes Doctors away from why they entered healthcare – to take care of patients. Health systems and private equity firms are increasingly investing in non-traditional healthcare settings, which has led to a rise in the acquisition of physician practices. These investments are not only aimed at financial returns but also at improving care delivery through enhanced management and infrastructure support92.

Moreover, the adoption of diversified business models that include a mix of traditional hospital services, outpatient care, and specialized clinics is proving beneficial. Such models facilitate better care coordination, reduce costs, and improve patient experiences91. The significant growth in telehealth adoption, which saw consumer usage surge from 11% in 2019 to 46% post-pandemic, exemplifies the shift towards more flexible, technology-driven healthcare solutions that could define future surgical practices91. However, recent data suggests a decline in telehealth following the peak of the pandemic and movement toward a new equalization of care.

Additionally, there’s a growing interest in alternative practice models like concierge medicine, although its viability in less populated areas remains uncertain94. These models offer a more personalized approach to care, which could appeal to patients and surgeons alike, looking for more control over their healthcare experiences.

As the surgical field continues to evolve, the role of surgeons will likely expand beyond traditional clinical duties to include leadership in healthcare innovation and practice management. This shift will require ongoing adaptation and flexibility from surgeons, as they navigate an increasingly complex healthcare landscape9294.

Professional Autonomy and Work-Life Balance

Surgical Professional Autonomy in Different Practice Models

Professional autonomy in surgery is a critical aspect that allows surgeons to exercise control over the organization and terms of their work14. This autonomy manifests in various forms, such as clinical work freedom, where surgeons have the liberty to decide on patient care without constraints imposed by organizational procedures or financial concerns1421. Additionally, surgeons can influence organizational decisions, contributing their insights into how their units and hospitals operate, which is vital for maintaining the integrity and effectiveness of medical services14.

In different practice settings, the degree of autonomy can vary significantly. Surgeons in private practice might enjoy broader autonomy concerning economic decisions like earnings and managing the volume of tasks21. Conversely, those in hospital settings might face more restrictions due to administrative oversight and ultimately less control. Many are happy to relinquish this control in exchange for benefit of focusing more on clinical duties without the burden of operational management21.

The concept of autonomy also extends to surgical trainees. Under the guidance of experienced surgeons, gradually gain independence. However, Surgical trainees report receiving little training on how to manage a private medical practice. The system of graded responsibility, less practice management, is a well-established educational model in surgical training, allowing trainees to perform tasks independently as they gain competence98.

Work-Life Balance Considerations

Achieving a healthy work-life balance is particularly challenging in the field of surgery, where the demands of the profession can overshadow personal needs, leading to burnout and dissatisfaction102103. Factors such as long working hours, extensive on-call duties, and the pressure of maintaining high standards of patient care contribute significantly to the stress experienced by surgeons101102.

Research indicates that elements like autonomy in scheduling and decision-making can mitigate feelings of burnout and enhance job satisfaction101. Innovative approaches in practice management, such as the integration of administrative support and flexibility in work hours, have shown promise in improving modern surgeons’ work-life balance103. For instance, systems or PE investors who structure businesses that allow surgeons to delegate administrative tasks and focus more on clinical responsibilities can lead to more sustainable work patterns and better personal well-being103.

Furthermore, the establishment of supportive work environments, where teamwork and patient safety are prioritized, can significantly affect the work-life climate, leading to lower burnout rates and better overall job satisfaction among surgeons102. These environments foster a culture of respect and support, crucial for maintaining both professional efficacy and personal health.

Finding the optimal balance between professional autonomy and work-life balance is complex and deeply intertwined with the structural and cultural elements of the healthcare settings surgeons operate in. Addressing these aspects holistically is essential for the well-being of surgeons, without compromising, and potentially improving delivery of patient care.

Challenges and Opportunities Ahead

Navigating the Changing Healthcare Landscape

The healthcare sector is undergoing significant transformations driven by various factors such as corporate entities, regulatory and legal shifts, financial models, new technology and the growing administrative burden. As these factors converge, they present both challenges and opportunities that require strategic responses from healthcare providers107.

One of the most pressing issues is the projected shortage of medical professionals, exacerbated by an ageing population with increasing healthcare demands and growing costs. With many physicians and nurses nearing retirement, the gap in healthcare provision is expected to widen, particularly in specialized and rural areas107113. This demographic challenge is compounded by the growing prevalence of chronic diseases along with the retirement and burnout of existing healthcare professionals leading to higher attrition rates107.

To address these shortages, healthcare organizations are urged to prioritize strategic workforce planning and training initiatives. Investing in education and training programs for doctors, nurses, physician assistants, and other allied health professionals is crucial to ensuring a sufficient workforce to meet the escalating demand107.

Moreover, the integration of digital technologies like telemedicine and remote patient monitoring is transforming healthcare delivery. These technologies enhance care accessibility and efficiency, particularly in under-resourced areas, by facilitating remote consultations and continuous monitoring of health conditions107. However, the adoption of these technologies also introduces challenges related to data privacy, security, and the ethical use of artificial intelligence in healthcare decision-making107.

Embracing Opportunities for Growth and Development

Amidst these challenges, there are significant opportunities for growth and development for physicians along with investors within the healthcare sector. The continuous evolution of healthcare demands that professionals not only adapt but also proactively engage in their professional development to keep pace with advancements109112.

Promoting a growth mindset among medical professionals can lead to increased resilience, improved clinical skills, and greater motivation. This mindset encourages viewing challenges as opportunities for learning and growth, which is essential in a rapidly evolving field like healthcare111. Medical education systems that emphasize effort and hard work over innate talent, and that view mistakes as learning opportunities, are crucial in fostering this mindset111.

Additionally, the collaboration with industry partners to evaluate ongoing innovations and the participation in continuous professional development activities, such as attending conferences and engaging in research, are vital for staying current with the latest medical practices and technologies112 and investing in relationships with other physicians who can support further growth and mental wellness. These activities not only enhance clinical skills but also ensure that healthcare professionals are well-equipped to deliver high-quality care.

Healthcare leaders are also recognizing the importance of developing and implementing effective leadership interventions. These interventions, aimed at improving leadership processes within healthcare, are crucial for enhancing the quality of patient care and ensuring the effective use of resources114. Adopting evidence-based guidance for designing and implementing these interventions can help ensure they are acceptable to the healthcare community and successful in achieving their intended outcomes114.

In conclusion, while the healthcare sector faces numerous challenges, it also presents ample opportunities for professionals to grow, innovate, and improve the quality of care provided to patients. By navigating these challenges and leveraging the opportunities for development, healthcare providers can ensure a robust and responsive healthcare system.


Surgeons today stand at the crossroads of a rapidly transforming healthcare landscape, navigating through shifts from private practice to hospital employment and grappling with the integration of private equity into the medical sector. These changes, while presenting financial and administrative challenges, also offer new realms of technological advancements and opportunities for redefining patient care quality. Through this exploration, I’ve highlighted how such shifts affect everything from surgeons’ autonomy and work-life balance to patient-doctor relationships and the overall quality of care, underpinning the critical balance between maintaining personal well-being and meeting evolving industry demands.

Looking ahead, the future of surgical practices is poised to be shaped by ongoing adaptations to new business models, regulatory landscapes, technological innovations, and patient behaviors. As surgeons and healthcare professionals seek to harmonize professional autonomy with enhanced patient care, their journey promises opportunities for growth within an industry characterized by relentless change. Embracing this change, while staying true to the core values of patient-centric care, professional satisfaction, and quality outcomes, remains essential for navigating the complexities of modern healthcare and ensuring the sustainability of surgical practices in a dynamic world.


  1. What advancements have been made in surgery in the 21st century?
    Surgery has seen significant advancements in the 21st century with the development of minimally invasive techniques, such as laparoscopic surgery, robotic surgery and office-based surgery which have the potential to greatly reduce cost, improve precision, shorten recovery times and reduce complication risks.
  2. What future developments are expected in surgical technology?
    Future surgical technologies are anticipated to further incorporate computer-aided systems such as robotics and image-guided surgery. These advancements will allow surgeons to perform procedures with precision beyond the current human limitations, particularly in operations on microscale structures or moving organs.
  3. How has the field of surgery developed over the past century?
    Surgery has evolved significantly over the past century with several key technological developments. These include Electrosurgery, introduced in the early 20th century; practical Endoscopy, which began in the 1960s; and advancements in the 1980s such as Laser surgery, Computer-assisted surgery, Robotic surgery, and the growing prevalence of office-based surgeries in the early 2000’s.
  4. What are the four key discoveries that revolutionized surgery?
    The four fundamental discoveries that have dramatically changed the field of surgery are the advancements in anatomical study, the development of anesthesia, the discovery of X-rays, and the implementation of antiseptic methods based on the germ theory. These discoveries have collectively transformed surgical practices and outcomes.


Greg is the senior director of business development and partner at Medfluence Advisors where he uses his more than 20 years of experience in the domestic and international healthcare industry to support those in the medical community achieve greatness. Outside of work, Greg is a private pilot, runner and yoga enthusiast.


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