Assembly line surgeons: Corporatization of medicine and its impact on vascular surgery

Older surgeons have lived this transition with chagrin and consternation. Younger surgeons, increasingly raised in the inherent shift work associated with mandatory duty hours, enter this environment perhaps unaware of what they missed but fully realizing the destination differs from their dream. How did we get here and what can we do about it? 

The corporatization of medicine is well documented. As of 2024, only 35% of physicians owned even a share of their own practice, a fall from over 50% in 2012. Those remaining in private practice are disproportionately older; only 25% of physicians under 40 were practice owners. The percentage of doctors who worked in a practice owned by a hospital, hospital system, or health system climbed from 5.6% in 2012 to over 80% today. Over three-fourths of hospital beds in the country are controlled by large chains or health care systems.  

Vascular surgeons are hardly immune from this movement. A 2013 study showed that around 24% of vascular surgeons were employed by a hospital. More recent, albeit less robust data, from 2021 suggested that number had increased to over 70% and those remaining in private practice tend to be older, suggesting this trend will only compound in the coming years. Private equity investment often maintains the illusion of physician ownership for legal purposes but usually results in a similar employee model through their management system.   

This corporatization has taken a significant toll on physicians and vascular surgeons, who have transitioned — willingly or not — from autonomous practitioners to employees. The sociological commoditization of physicians has enormous implications. It fundamentally reshaped the doctor-patient relationship from a sacrosanct bond to a more commercially focused, transactional partnership exacerbated by an increasing shift work model and mindset. The evolving language embodies this devolution, with physicians now “providers” or “practitioners” whilst patients become “health care consumers.”  

In partially losing their identity as doctors, they transform into revenue generating units for a hospital system. Implanting aortic grafts is vastly more complicated (and remunerative) than implanting brake pads on a Ford assembly line, but the structure and culture around the work increasingly overlap. Watercooler gripes in both workplaces center around PTO, benefits, reimbursements and struggles with upper management.   

When doctors are judged on transactional performance metrics, it prioritizes the economics over the clinical care. This trend exists not just in private practice. Academic institutions continue to elevate productivity — as defined by RVU generation — over their other core missions of research and teaching; multiple studies have warned of the disappearing surgeon-scientist. Vascular surgeons have never worked for free, but they previously defined themselves based on their accomplishments in the OR, the lab and the classroom. Money followed but was not the driving force for most. The organizational prioritization on the bottom line alters professional incentivization and the focus of who we are.   

This loss of identity is contributing to burnout. AMA data identified a physician burnout rate of around 42% nationally; a 2018 SVS survey found 41% of vascular surgeons presented with symptoms of burnout and 8% had considered suicide in the previous 12 months. Study after study show doctors continuing to derive deep meaning in their clinical care but increasingly frustrated with the bureaucracy, paperwork and organizational subservience.  Vascular surgeons often jokingly refer to themselves as white-coat plumbers, repairing leaking pipes and opening clogged ones. Yet in a key distinction, a 2024 survey showed over 90% of plumbers were satisfied with their jobs. Vascular surgeons should be so lucky.   

Market incentives ensure that the corporatization of medicine and of vascular surgery is not reversing anytime in the near future, so what can we do to combat the loss of autonomy?  Unionization is one option. Historically utilized by laborers to create a fair negotiating platform, unionization has traditionally been an anathema to professionals such as physicians. But in an era when most physicians owned their own practice, against whom were they negotiating? No need existed. As doctors become one of an organization’s thousands of employees paid a set salary to execute a specific set of responsibilities, then unionization made more sense.  

Between 2014 and 2019, the proportion of unionized physicians grew 26%. Doctors at Kaiser Health are unionized, as are 400 PCPs at Allina Health in Minneapolis, along with the anesthesiologists at Cedars-Sinai; those at Banner Health in Arizona and other large health care systems are actively exploring this option. Of course, many house staff now also belong to unions. Like it or not, this trend will continue. 

Unionization as a concept still rankles many clinicians; an alternative might be trade groups, not so different from the medieval surgery guilds whence our profession originated. Guilds engaged multiple skill levels, from the novice through master, according each a commensurate degree of responsibility, both to patients and to the organization itself. Unlike unions, they permit the inclusion of supervisors such as division chiefs as well as private practice surgeons.  

Focusing on the nuance of the craft and the art of the work itself (e.g. the screen actors guild), guilds could highlight and promote the best of vascular surgery. Assuming a less adversarial posture than unions, said guilds would focus on clinical outcomes and professional satisfaction rather than wages. It seems unlikely any national guild could effectively represent disparate local interests, making a series of local organizations the most realistic option.   

“The good old days weren’t always good / and tomorrow ain’t as bad as it seems,” croons Billy Joel in one of his ballads. Medicine and vascular surgery have never been perfect. Moreover, much of the future is tremendously exciting: the next generation of doctors are smarter, more diverse and arrive with greater research experience than any who preceded it. Technological innovations, increasingly married to artificial intelligence, will continue to reimagine and reshape our field.  

Yet some things don’t change, like surgical pathology.  A hole in the artery in 2026 differs little from a hole in 1026 from a hole in 3026. And while tomorrow’s doctors may be better equipped than ever to fix that leak, vascular surgeons ought to be more than glorified plumbers, even if that is how corporate medicine currently treats us.

Samuel Money is emeritus professor of surgery at the Mayo Clinic College of Medicine and professor of surgery at Xavier-Ochsner School of Medicine. Justin Barr is a staff surgeon at Ochsner Health in New Orleans, Louisiana.