What’s In It For Me?


An entitlement culture is one which says, “you owe me” because of who I am or what status group I belong to. While some have argued that such a mentality has been on display in the Occupy Wall Street movement – young people believing that they are “owed” a job because a small percentage of the population earns a lot of money – they are certainly not alone.

How the entitlement culture can sink emergency medicine contract management groups.


An entitlement culture is one which says, “you owe me” because of who I am or what status group I belong to. While some have argued that such a mentality has been on display in the Occupy Wall Street movement – young people believing that they are “owed” a job because a small percentage of the population earns a lot of money – they are certainly not alone. Entitlement cultures can exist in business organizations as well, including emergency medicine group practices, and it’s an infectious problem that must be dealt with if a group is to thrive.

In businesses that have allowed an entitlement culture to develop, employee focus is biased toward what the business can do for the employee to the detriment of what the employee should be doing for the business. All business-employee or medical practice-partner/owner relationships are based on an underlying quid pro quo, which is that the business is there to sustain the employee or owner provided that the employees and owners act in such a way as to sustain the business. Yet it is not hard in such organizations to find evidence that this bargain is being regularly broken. Employees feel entitled to carry off supplies for personal use or copy the PTA meeting agenda without reimbursing the business. The practice of providing paid sick leave, put in place to aid and protect the unfortunate employee struck by illness, is now seen as a universal benefit to which one is entitled and to be taken whether there is sickness or not. And of course all kinds of games are played with expense reimbursement, none of them to the benefit of the company.

In emergency medicine group practices, the entitlement culture view of the world is most obvious among a certain group of new residency graduates. They have been taught by their mentors that they are entitled to be given group ownership, high pay and benefits for a minimum of clinical work and accountability to the group, solely because they belong to what they believe is an elite group of residency-trained emergency physicians. But this is no different than what goes on in many independent emergency medicine groups where some partners receive privileges or benefits based solely on their seniority, or the fact that they started the practice thirty years ago. At its worst, entitlement in these kinds of practices manifests as a pass on confronting bad behavior or sub-standard clinical practice on the part of a partner or owner. The big question is: How many physicians with an entitlement view of their group can a group practice tolerate and still be competitive in today’s increasingly competitive emergency medicine world? The answer, in my opinion, is none, because if the group is tolerating it in one person it is likely tolerating it in all and as Mitch Free wrote in The Street: “Entitlement is often a fatal infection.”


All enduring businesses and emergency medicine groups are meritocracies to one degree or another because the truth is, as Medal of Honor winner, POW, and Vice Presidential candidate Vice Admiral James B. Stockdale has stated: “Entitlement and privilege corrupt.” Not only that, but they sap morale and degrade productivity too. Those in an EM group who argue against productivity-based compensation may be opposed to it because it threatens their entitlement to the same rate of pay regardless of practice contribution. The successful business or practice prospers when all of its members are held accountable for their contributions; for their side of the bargain. An additional truth is that making the cultural transition to, or re-establishing, merit and accountability in an organization like an emergency medicine group is not easy and requires hard decisions and hard interpersonal work. Some key steps in the process might be as follows:

1) Create a strategic plan that clearly recognizes the different types of work necessary in an EM group practice (clinical, leadership, administrative, and ownership) and resolve to hold those doing each kind of work accountable for their results and compensate them accordingly.

2) Begin immediately to recruit new partners with strong ethics who recognize that accountability is as much a part of a healthy group practice as entitlement.

3) Re-design your orientation program to be certain it clearly communicates the expectations from the individual in each type of EM group work.


4) Implement an accountability system that objectively measures performance and results, and have the discipline necessary to provide regular performance reporting to new hires, senior partners and everyone in between.

5) Implement self-directed, self-managed, owner-led Project Teams. This engages the owners, leverages the group’s power, and identifies and trains succession candidates.

6) Implement a progressive disciplinary system that confronts problems early, provides terms of satisfaction for correction, and holds the individual accountable for meeting them. Impose meaningful consequences if the terms of satisfaction are not met.

7) Provide opportunities for group members to grow in their non-clinical capabilities in the areas of relationship, communications, and project management.

8) Regularly and publicly acknowledge those that are outstanding in their commitment to the practice and its goals and objectives.

Hanging in there with the status quo when your group has drifted into an entitlement culture is like going with the river’s flow: it seems so safe and easy until you round the bend and see the falls ahead. There’s never a perfect time to address your group’s culture but the people who are actively paddling are rarely the ones ending up on the rocks below the falls.

Ronald A. Hellstern, MD, is the Principal & President, Medical Practice Productivity Consultants, Dallas, Texas


  1. Of course that entitlement mentality can work in the other direction too. An administrative job should be just that – a job, not a welfare program for older doctors. Administrators should be paid fairly for their work; no more and no less. Those who maintain the group and protect the contract should not be taken advantage of, but neither should the workers who generate the group’s revenue by taking care of patients.

  2. I agree that among graduating residents there exists an entitlement that as they come out of prestigious academic institutions having weathered residency with accolades that they believe they are owed the promise of prosperity that society in general told them would be waiting for them. Of course, reality sets in and you realize that student debt, and housing prices make for an unwelcome mat; your new job is more intense than you expected (despite your great training) that documenting well and billing well while conveying a deep sense of concern for patient discomfort and understanding to max out your Press Ganey score and keep the nurses and consultants happy is a lot harder than it looks. But within 2 years you are more then capable of maxing the RVU and Press Ganey simultaneously and found a way to turn the grouchy cardiologist into a teddy bear that gushes when you defer to his great intellect. And by now you are starting to spend additional free time attending hospital committees that support the overall improvement in patient care and cement your groups contract. But….your senior colleagues are not going to divulge the whole extent of how your efforts fit into the business plan. There may be a semi-quantitiative rank listing of your RVU’s and Press Ganey but the actual impact your work has on actual reimbursement will remain a mystery. The contract owner / your employer is rarely a meritocrat, he/she/they have built a business that supplies physician FTE and this will provide some level of profit that is acceptable to all share holders. Those shareholders are not likely to divulge the profit margin they are comfortable with before inviting an additional shareholder anymore than KFC is going to tell you which 11 herbs and spices they are using. The scrutiny of your productivity will continue but only because it serves to keep you in your place, the contract owner is less concerned with their own productivity relative to the employees. And then the realization that after all your handwork and dedication to patient care and high productivity that you are an employee rather than captain of your own ship sets off a desire to have some ownership in your practice, only now you might be ‘entitled’ to nothing more than the old song and dance of how the contract has been in place for 20 years because of the owner’s prescient ability to weather the difficult tasks of surviving multiple administrators. Most community contract holders do not supply a transparent process of business profit and loss, nor how every physician fits into that equation. The fact is that when you start you will generate a substantial revenue that will pad the profit margin and if you want to know just how much padding that is well don’t ask unless you want to be labelled as having an entitlement complex. It is imperative that contract holders lift the veil of secrecy and have a frank and transparent discussion about the business of EM. Physicians are not typical employees that aspire to work for someone else, we all wish to have a turn at the helm and ignoring that may result in fueling mutiny. If business were a meritocracy then the best person for the job should be compelled to compete for the contract even if that is from within the employee pool. Let’s hope that we all feel entitled to deal with each other fairly and openly on all aspects of the business of EM. And of course remind ourselves that caring for patients matters most.

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