https://www.medpagetoday.com/opinion/second-opinions/118254?trw=no

For more than a century, American medicine has been anchored by the independent physician -- a professional who owned their practice, managed patient care, and participated in civic medical life through county and state societies. That archetype is fading fast. A growing majority of doctors now practice as employees, and this shift poses an existential challenge for medical societies built around a model of independence that no longer reflects reality.

The End of the Independent Majority

According to the American Medical Association (AMA), 2020 marked the first time that fewer than half (49.1%) of physicians worked in doctor-owned practices since their tracking began. By 2022, that number had fallen further to 46.7%, down from 60% a decade earlier. Meanwhile, the share of physicians employed by hospitals and health systems has expanded sharply -- from about 29% of physicians in 2012 to more than 40% in 2022. Private equity ownership, virtually absent in previous decades, now accounts for roughly 5% of physician employment.

The forces driving this shift are not ideological -- they're economic and administrative. Four in five physicians who moved to employed settings cited better leverage in payer negotiations, while 70% pointed to relief from the regulatory and operational burdens of solo practice. For many, aligning with larger entities was the only way to survive in today's complex reimbursement and compliance landscape.

The Membership Decline Crisis

This employment transformation has disrupted the very institutions meant to represent physicians. Nationally, AMA membership has plunged from about 75% of U.S. physicians in the 1950s to just 15% today. State and county medical societies mirror this pattern, facing shrinking memberships, aging leadership, and limited engagement among younger doctors.

Specialty societies have filled much of that vacuum. Groups like the American College of Physicians, the American College of Surgeons, and the American Academy of Family Physicians have seen significant growth over the past few decades. Their rise underscores a broader shift in professional identity -- toward communities defined by clinical specialty rather than geography or general advocacy.

Local societies, meanwhile, often lack the infrastructure and staff to deliver value commensurate with membership dues. Though they continue to offer CME events, scholarships, and social gatherings, these efforts rarely outweigh the time and cost constraints on modern employed physicians.

The generational divide adds another layer to this challenge. Many early-career physicians do not view large medical society participation as a professional obligation. The younger cohort sees medicine less as a life-defining calling and more as one component of a balanced life. Sociologist Robert Putnam's "bowling alone" thesis applies neatly here: today's physicians are more networked digitally but less connected institutionally. That pattern makes traditional membership recruitment difficult.

A Profession in Search of Voice

The transition to greater physician employment by large health raises important questions about physician satisfaction and professional autonomy. On the one hand, employment by a large hospital or health system can, at times, help improve practice environments and address organizational and systems issues that previously fell on independent practitioners.

Yet, there's a paradox: even as some workplace stressors ease, many doctors feel a loss of autonomy.

Physician trust in the organizations that employ them has eroded. Fewer than half now believe their leaders are honest or transparent. Only 47% say they trust leadership to make patient-centered decisions -- a decline from 53% the year prior. This disconnect signals a deeper identity tension: the corporate healthcare environment often values efficiency, while physicians are trained to value individual patient outcomes.

The trust gap appears wider in nonprofit hospital systems than in investor-owned or private companies, a counterintuitive finding that may reflect communication styles more than structural differences. Whatever the cause, it reinforces a growing unease among employed clinicians.

Unionization and Collective Advocacy

This erosion of trust has quietly fueled another development -- rising physician interest in unionization. More than two-thirds of doctors have a favorable view of physician unions, though only about 1% belong to one.

That sentiment reflects a hunger for collective representation beyond the confines of their employers. It also hints at a potential opportunity for medical societies: to reclaim relevance by becoming independent advocates for physicians' professional interests in a corporate-dominated environment.

Reimagining the Role of Medical Societies

Medical societies no longer have the luxury of nostalgia. Their path forward requires redefinition, not restoration.

First, societies must pivot from being membership clubs for practice owners to advocacy anchors for all physicians -- employed or independent. Employed doctors face unique challenges around contract negotiation, compensation structures, noncompete clauses, and performance metrics. Medical societies are well positioned to provide impartial guidance, legal resources, and leadership training that employers cannot.

Second, societies should expand their advocacy portfolio beyond legislative engagement. The most urgent concerns for physicians -- prior authorization reform, electronic health record usability, and administrative overload -- transcend employment status. Medical societies that push for practical system-level improvements can demonstrate immediate relevance.

Third, societies should adopt new membership models that reflect the time and financial constraints of today's workforce. Tiered memberships, institutional partnerships with health systems, or free basic memberships supplemented by value-added services could attract early-career physicians who might otherwise remain disengaged.

From Organizations to Movements

The concept of "system citizenship" emerging from medical education circles offers a useful philosophical frame. It encourages physicians to see themselves not just as clinicians, but as stewards of the healthcare system itself -- balancing organizational, patient, and community health. Medical societies can become conduits for this kind of engagement, helping physicians bridge the divide between frontline care and system-level leadership.

If medical societies cling to models built for an independent-practice era, they risk fading into irrelevance. But if they harness their history of advocacy to address the lived experiences of employed physicians, they can reclaim their place as essential professional anchors.

Ultimately, the employment shift is not the end of physician community -- it's a call to redesign it. Medicine's next chapter will not be written by individuals working in isolation, but by institutions that adapt to represent physicians where they are -- within the systems that now define their professional lives. For medical societies, survival will depend on whether they can translate that reality into renewed meaning.

Hemant Kalia, MD, MPH, is councilor, 7th District, of the Medical Society of the State of New York. Kalia is a dedicated physician, specializing in interventional pain medicine, and a public health advocate. Mark Adams, MD, MBA, is president-elect of the Medical Society of the State of New York. He is a board-certified radiologist, and a professor of Clinical Imaging Sciences at University of Rochester Medical Center. David Jakubowicz, MD, is president of the Medical Society of the State of New York. He is also director of Otolaryngology and Allergy at Essen Medical, and a clinical assistant professor of Otorhinolaryngology at Albert Einstein College of Medicine/Montefiore.