Let’s start by defining the term “democratic” group. It is difficult to define since the term means different things to different people. For the purposes of this article I define a democratic EM group to be one in which:
(1) Every physician practicing full-time with the group is either an equal owner/partner or on the way to becoming one.
(2) All decisions are made by simple majority vote of the membership.
(3) There is no buy-in or buy-out for one’s partnership interest other than perhaps for a proportionate share of the accounts receivable.
The buy-in, if any, is typically managed through the sweat equity arrangement of a reduced compensation level for one to two years. By inference then, the practice is considered to have had no start-up costs, either economic or personal, no development or expansion costs, and no good will or going concern value. In other words, the practice, as distinct from its partners, has no value whatsoever. The newly minted emergency physician simply shows up with his stethoscope, is accepted into partnership, practices his profession for his allotted years, and departs. Nothing is invested; nothing is gained or lost. In this context the most successful democratic practices are considered to be those that minimize leadership and administrative costs in order to maximize physician take-home compensation without losing the contract in the process.
If this sounds too good to be true that’s because it almost always is! This democratic practice ideal exists, if at all, only in the minds of those who have never tried to create and sustain such a practice or for the brief period preceding the loss of the contract to a better led and-managed EM group.
This is not to say that there aren’t successful democratic EM group practices but rather that those that succeed and endure do so by recognizing the weaknesses of the ideal construct and devising ways to compensate for them. What follows is a discussion of the most significant of these weaknesses.
We see this phenomenon at work in democratic groups when individuals who are quick to call themselves equal owners or partners, but are slow to respond to e-mails, return phone calls or come to meetings. These same individuals typically avoid making other contributions to the group’s welfare such as service on a hospital committee, participation in nursing in-service education and meeting their minimum medical staff meeting requirement. We see it again when those who choose not to participate in protecting and maintaining the resource (the practice) then argue that those who do shouldn’t be paid the same hourly rate that they get to practice clinical medicine.
When the inevitable crisis arises, these “fair weather partners” have little interest in committing the time, effort or money needed to address the problem and wouldn’t know what to do even if they did. And so the contract management group (CMG) wins another contract almost by default. Worse yet, the hospital administration, having experienced the frustration, cost and complications of trying to work with a dysfunctional independent EM group, will not be willing to risk such a solution again for many years to come.
-Define partner/owner responsibilities, keep track of who is meeting them, and vary the owner distribution in proportion to who is carrying the burden of protecting and nurturing the practice.
The old doctor group joke says it best: “What do you call a vote of 9 to 1 in a 10-person democratic group? A tie!” The democratic group quite often can’t make a decision without unanimous concurrence. Or, the group changes its mind before the decision is implemented if someone has second thoughts. Such a situation means that it is often the least motivated or informed member of the group that controls the organization’s agenda and pace. The resulting loss of direction and momentum leads to the inability to respond appropriately to critical issues in a timely manner, thereby undermining the group’s organizational competence and putting its contract at risk.
When everyone is equal who is to lead? Who’s to hold the other group members accountable for doing what they have committed to do? You can’t tell an owner what to do, right? Wrong! In every successful democratic practice someone has to be given both the responsibility and authority to lead, to make binding decisions on behalf of all of the group’s members, and to hold individual group members accountable for doing what the group has decided it will do. “You can’t tell an owner what to do” is a common democratic group refrain. Without the power to enforce discipline and the backing of a majority of the group when a hard decision is made the group leader’s job is made untenable and is both a waste of the leader’s time and the group’s money. Democratic EM groups are notorious for their failure to adequately discipline themselves.
Democratic EM groups frequently suffer from two mutually reinforcing misconceptions. First, that all non-physician business administration is parasitic, and second, that intelligence is always a ready substitute for specialized management knowledge and experience. Too many groups use physicians in administrative positions that would be better and more cost effectively filled by non-physicians. The problem is not that physicians aren’t smart enough to be the best coder or recruiter or benefits administrator that ever was, but rather that they don’t know what they don’t know about the particular administrative area because they have no basis of reference and because they can’t devote their full attention to these jobs.
Fred Kofman, in his book Conscious Business, talks about the distinction between being a “Learner” and a “Knower.” All physicians are programmed to be “knowers,” probably from an early age. The pressure to deny your own limitations and know the right answer in medicine is at times near overwhelming. What makes us good physicians hampers us in business because good business management requires that you acknowledge your own limitations and seek help when it’s appropriate, and that you be constantly open to new ideas and change. Being a “Knower” means having all the answers or at least appearing as if you do. Being a “Learner” means publicly acknowledging that you don’t.
The best compensation for this weakness is to seek to utilize full-time non-physician specialists in each area of practice management to the greatest extent possible. Leadership requires that the leader “know” there is a better way and be able to communicate that vision to the emergency department team. Physicians should lead and delegate management tasks.
Management’s job is to maintain the status quo as inexpensively as possible while being constantly open to changes in the field and new ways of doing things. Leadership’s job is to anticipate change and guide the organization’s adaptation to it. The group’s leadership should be giving management new marching orders at least once a year following the ownership’s annual strategic planning session. Don’t fall into the trap of letting the EM group’s members shirk their leadership responsibilities because management tasks are so much easier and comfortable for them to do.
Long term organizational success starts with clarity about your mission (your reason for existing), your vision (what you aspire to become) and values (the values you will uphold as you seek to achieve your vision). The second of Stephen Covey’s 7 Habits of Highly Effective People is to “begin with the end in mind,” but few EM groups, democratic or otherwise, take the time to define themselves and their aspirations. Is it any wonder that they then have trouble succeeding when they haven’t defined where they are going, why they want to go there, and what they will expect of their members as the journey unfolds?
The strongest EM groups take the time to define their mission, vision and values and work to keep them alive in the organization. This as much as any of the other compensating measures will keep your group from floundering in indecision and bolster you in making the hard decisions that assure the continuity of your business.
Ronald A. Hellstern, MD, FACEP is a principal and senior consultant with Medical Practice Productivity Consultants, LLC, Dallas, Texas. He can be contacted at firstname.lastname@example.org