Advocacy’s Role in the Democratic EM Group - Democratic Group Practice Section Newsletter, September 2011
Martin E. Ogle, MD, FACEP
As a Partner in a Democratic EM Practice, I appreciate that I am an owner of my group and a practicing emergency physician. I like to think of it as I’m an owner and an earner. This is an important structural advantage that democratic EM practices have because there can be times when owners and earners may be at odds over issues. For example, if I am an owner but not an earner, I may want to minimize my physician salaries to make more profit. On the other hand, if I am an earner but not an owner, I want to maximize my current income and not necessarily invest in the long term strength of the practice. But, if I am both an owner and an earner, I need strong provider compensation as much as possible AND continue to strengthen the practice for its long term success. I must find this balance if I am to contribute to a thriving EM practice.
An example of how this democratic EM practice/owner-earner structure works, one need look no further than the role we play with political advocacy. I know that I need to advocate on behalf of my patients and the practice of emergency medicine if the practice, as we know it, is to survive and flourish. I also know that these sorts of endeavors come at a cost; support of organized (emergency) medicine to speak on our behalf, support of our representatives in government who are sympathetic to our issues, and support of our physician partners who are willing to spend significant amounts of time educating our politicians on topics. As a Democratic EM Group practice that serves several hospital clients, we have decided as a group to set aside a few cents from every patient encounter to invest in the future of the practice and help manage the political forces affecting the practice of emergency medicine. Could I make a few more pennies per hour by not doing this? Yes, but at what cost long term. Again, this is the balance of maximizing compensation and investing in our practices. Whether your democratic EM practice is a single hospital practice or multiple, I would strongly encourage all owner/earners to get involved.
The Democratic EM Group Experience - Democratic Group Practice Section Newsletter, September 2011
Ron Hellstern, MD, FACEP
Working in a business you own is altogether different than working in someone else’s business. I started out in 1978 as a sole proprietor and genuinely missed having partners to share the burdens of ownership of a 24/7 business. Potential partners came along, but when given the chance to lead they “forgot” to do key tasks or they caused more upset than resolution when dealing with problems, and they were constantly measuring their contribution to the business against their current compensation. Unless a potential partner was willing to share my “whatever it takes” commitment to the business it seemed to me that I would be carrying them more than they would be carrying me. Partner inequalities like that breed resentment sooner or later, and so I said no thank you.
Then I had my first myocardial infarction at age 43. I “owned” 17 urgent care facilities and 3 ED contracts at the time but owed 200% of my assets to someone or the other. I was a smoker with elevated cholesterol and a bad family history, but the crowning blow was my teenage daughter, for whom I had been a single parent for 3 years, turning 15 (the age of majority in Texas) and announcing that she was moving back with her mother. The old heart just couldn’t handle any more abuse. As I was recuperating I began to think about what might have happened to all those people working for me had I died a sole proprietor. I made up my mind to: (1) sell the urgent care business, and (2) find at least one partner to share the workload.
As luck would have it I ended up recruiting four emergency physicians to be my equal partners only to discover that none of us really knew what being an equal partner meant, me least of all. In general, they had to get clearer about the level of responsibility they were taking on as an owner and I had to learn to be more of a consensus leader rather than a benevolent dictator. Some of my past companies still work with the same business relationship and communications coach we hired to help us learn to be good partners, and our practice prospered. In eight years we grew from 3 to 23 ED contracts and eventually to become a 500-provider DFW multispecialty group. Along the way four of us asked the 5th to leave because we didn’t feel that he was matching the rest of our commitment level, and we paid him handsomely for his shares. Other partners came along to join the original four and life was hard but good.
Though it was stressful and painful at times, I value the personal growth experience of learning how to integrate myself into an equal partnership. My partners enabled all of us together to accomplish more than what any of us individually would likely have been able to do and all of us grew in both emotional maturity and business capability. Most felt they were significantly better off financially than if they had not been partners in building the business, although one felt cheated by the size of his equal share compared to the sacrifices that were required and held onto that grudge in perpetuity.
The concept of making someone an equal partner just for showing up and working their clinical shifts would never have occurred to me and my partners. Being a partner in our group was mostly about meeting obligations, particularly in the beginning, without knowing if you would ever reap the reward of those sacrifices. At the same time full partnership was wide open to anyone willing to play at the same, “whatever it takes” level. I am all for democratic groups but my expectations of an owner seem to be at considerable odds with the rather loose criteria for equal ownership in most such groups today.
Sometimes the Grass is Greener - Democratic Group Practice Section Newsletter, September 2011
Travis Fawver, DO (Not an ACEP member)
My immediate reaction to being asked to write a short piece about my experiences in a democratic physicians' group was one of apprehension. As a relatively new member of a democratic group, I was sure I did not have enough experience and no one had ever cared about my experience within my company before. Conversely, this may be the best time for me to share my thoughts as my recollections of past disappointments and present successes are fresh.
In training, I assumed if I worked hard and amassed qualifications I would be eagerly pursued by a vast number of organizations. Naturally, these groups would be just as eager to embrace my efforts to invest myself in the group. If I demonstrated ambition, they would take an active interest in developing my capabilities and guide me up the rungs of success. Sadly, my experience in organizations that are not physician-centric served to rapidly erode these expectations. I had all but given up and was prepared to resign myself to the role of shift worker. I never felt truly engaged by my company, I definitely did not feel involved and I was painfully unfulfilled professionally and personally.
Physicians have invested so deeply in their careers they desire some sense of control and involvement in their duties. I experienced nothing of the sort in non-democratic groups. The layers of bureaucracy were so dense I never felt as if I truly knew who was running the show. I was never engaged or contacted by anyone above my immediate directors. I felt as if there was a standing policy to keep physicians isolated and anonymous within these organizations. You never received feedback about how you were doing at work unless it was negative. You never knew where the company was going until it was there.
Then there were always the little surprises like losing/changing schedulers randomly without being informed and receiving your schedule a week before the month started. We frequently discovered executives and people we trusted for years suddenly disappeared from the company without warning. For years, I offered to take on more responsibility and involvement and was generally ignored. When I was finally given a role, I was still kept at arm’s length. I felt like there was a constant game within the company to keep information and power from those working in the trenches. There was a small group of people with a death-grip on influence and there was no way they were relinquishing it.
As fate would have it, I crossed paths with a colleague who had suffered through some of the same tribulations as I while he was working for the same non-democratic company. He had worked in a democratic group for several years and attained great success and fulfillment in a short time through his own ambition and hard work. Remarkably, his company seemed to function openly and embrace physicians with ambition. It really seemed like a bunch of snake oil at first, but I eventually realized this group shared my beliefs and I wanted to be part of it.
So what have I gained in my short time with a democratic group practice? A group of colleagues who engaged me immediately and recognized I had something more to offer than shift work. An immediate level of responsibility I had not achieved even after years with my previous company. Opportunities for training, personal involvement and financial investment in my company. A sense of fulfillment I had always expected after years of arduous training. I know the rest is up to me, but at least I know what is happening around me and that I can be a part of it every day.
The Collaboration and Competition amongst Democratic Groups - Democratic Group Practice Section Newsletter, September 2011
Savoy Brummer, MD
Wesley Curry, MD, FACEP
The world keeps on getting smaller. When democratic organizations compete in similar markets, the altruistic values of collaboration that define our practice model are weakened by the skepticism and fear of cultural and fiscal viability.
Throughout our training, we developed relationships that were forged by the trials and sacrifices of our education. However, these relationships waned as we entered our professional careers. Many friends and collaborators moved on after medical school and residencies, and joined different ED groups throughout the country. This was not always because that particular group was our preference, but because our job, family, or personal reasons directed us towards a particular location. We also became aware as we looked for jobs, that there are many attributes that describe an emergency physician practice. This included location, hospital type, business model, ownership, number of hospitals in the group, equity distribution, cash flow, incentives, and physician status such as independent contractor, employee, shareholder, partner etc. Now emergency physicians in general have a bewildering array of emergency physician practices to choose from as a career choice.
The comments in this article however are not an attempt to further define a democratic group. This is also not a diatribe focused on a particular emergency medicine business model. The opinions expressed here are our own, but we have a broad perspective. We are in separate democratic emergency physician groups based in the same state, but with practice locations in many other states. We also have gained our perspective from our own efforts to collaborate and compete as well as to do the same with other “democratic groups” which represent hundreds of other emergency physician practice locations throughout the United States.
In effect we realize that there is ample advantage in both collaboration and competition with other like minded democratic emergency physician groups. We must preserve the viability of our practice model for the next generation of emergency physicians who desire to work in our business model and enable our current emergency medicine practices and compete successfully against other business models in the future to grow the aggregate number of democratic group practices nationwide. After all, one emergency physician group’s success is another emergency physician group’s failure. The hospital does not care about whether a physician group is democratic or not, only whether the new group will be able to integrate into its challenges and opportunities to help it achieve its mission and realize the hospital’s vision.
This is the first of a series of articles, written by physicians of different competing emergency medicine organizations, that hopes to discuss several areas in which democratic groups can find ways to collaborate. As this is the first in the series, we will discuss how collaboration can improve the foundation of any group; structure and recruiting.
The foundation of any democratic organization is its structure. We commonly ask our fellow organizations, “just how democratic are you?” This is not just an academic argument regarding our peers; rather it is more commonly an attempt to define ourselves. Every democratic organization strongly encourages it partners to get involved politically, financially, and culturally. Whether democratic groups have shareholders or partners or owners, each was formed to translate their interests into a working business paradigm. Unfortunately, we commonly communicate to our own members and to all others, that our structure may not be perfect, but clearly more perfect as it relates to others. As two emergency physicians our choice was the democratic group practice model, which has always been difficult to define. We know and accept that like other business models, democratic groups are a true spectrum when one democratic group is compared to another. We believe democratic groups are essentially variations on the same theme, whereby the attributes of ownership distribution, governance, management, cash flow, profit distribution, and organizational values are structured to benefit primarily the individual physicians in the group and not investors or a limited number of owners.
Making disparaging remarks about other democratic groups is perhaps too common a practice and is detrimental to our organizations separately as well as in the aggregate. Within our own organizations, this assumption creates an increasingly, inflexible standard for the future. The dexterity that all groups will require to meet the needs of a growing diversity of individuals, contracts, and even specialties is compromised. To those outside our organizations, this communicates a message founded in arrogance that separates us from collaboration instead of bringing us closer together. Respecting the autonomy and differences of democratic groups represents our collective strength and not our weakness. Our competitive spirit and desire to improve ourselves should lead us all to listen to those organization’s whose structure differ from our own. Perhaps we can gather pearls that will improve our own group practice governance and management infrastructure and effectiveness. If someone else has adequately addressed a practice issue, why spend more resources and “re invent the wheel.”
Collaborating in terms of structure can be easy. Inviting colleagues, yes even “pit docs” from other organizations to meetings is a great start. There are few secrets between us in emergency medicine. Asking other democratic group leaders to speak at BOD meetings to discuss some of their history and trials is an illustration of strength not weakness. Sharing platforms and events at ACEP or other functions really encourages the cross breeding of ideas.
When most groups interview candidates, all we really want to see is if the physician can hold together his own psychopathology for 30min time interval. Is it really that simple? The short answer is YES! Emergency physicians are more talented than ever and groups must compete for the short supply of this talent.
Unfortunately, in competing for this talent, competing democratic organizations may disseminate inaccurate information regarding the other. When we propagate this negativity, it is a poor reflection of the culture that exists within our own organizations. We believe that it is in the best interest of our practice to maintain the integrity of other democratic groups. Indeed, when we encounter exceptional candidates who may not have a place or fit into a site within our organization, we should collaborate and even refer them to another democratic group that may have a practice location which meets their needs and professional interest. We could also consider joint recruiting venues where multiple democratic groups both small and large can share the expenses in a program to give an even larger group of emergency medicine residents than we could attract individually, an opportunity to learn about a variety of practice opportunities in multiple geographic regions. This culture would create a win-win situation in terms of collaboration for each emergency physician group, the candidate, and our respective practices as a whole.
In the next of our series of articles we hope to discuss how collaboration may exist in the settings of contract acquisitions and politics and engage in thoughtful and perhaps disparate views regarding the future of our practice. Indeed, competition will always remain. Democratic groups are unique in that they operate and have succeeded with a business model in contrast to others who have chosen to do business differently. Our pathway for the future is not based on creating value by monetizing the future earnings of our physician partners and shareholders. Likewise democratic groups are unlikely to tolerate disparate financial benefit by a few physicians at the expense of the vast majority of physicians in the group practice. This is a healthy equitable approach and if kept in perspective makes all of us better. However, in the end democratic groups must really consider who we are actually competing against. Is it other democratic organizations that share our practice model, or are only large, corporate, publicly traded entities? Make no mistake, there are large well funded private and public entities that are betting and indeed investing in an assumption that ‘democratic groups” cannot master the complexities of our practice environment in an era where we have to demonstrate value to our healthcare partners. We should not be criticizing non democratic groups and their business models, instead we should focus on how democratic groups large or small can collaborate, compete, and excel at keeping our current ED contracts and gaining new ones when others fail.
We are actively seeking comments from others in democratic groups regarding this series of articles. Please send your comments to Savoy Brummer so they can be included in the next discussion. A great example is the comment below by Mike Osmundson, MD, FACEP who helped edit this article.
“While nominally competitors, democratic groups have far more in common than they do differences. We each have a profound belief that physician ownership, physician leadership and democratic governance is the best model to align the goals of our physicians, hospital partners and patients. Sharing these beliefs and values means that each democratic group is vested in the success of other like-minded groups.”