September 23, 2019

“With great power comes great responsibility” - Stan Lee

Equitable distribution of shifts, income, and governance attracts many residents to a democratic group practice model.  Translating this desire for power into the responsibility of managing a practice can be difficult for many groups and begins with defining what it means to be a partner in a practice.

Democratic groups have a wide definition of partnership track.  Our group guarantees a partnership vote within 15 months of start date.  This is partially due to an exodus of staff after becoming a democratic group twenty years ago as well as the location of our practice in Milwaukee, Wisconsin.  Not many residents from the coasts want to move to the upper Midwest which makes recruiting a challenge at times.  The short partnership track has helped us easily recruit mostly chief residents from local emergency medicine residencies.  We require everyone to participate in some type of meeting or project.  It could be as simple as attending the quarterly antibiotic stewardship meeting or giving a resident lecture once a year. 

Developing a pathway to transition high-achieving residents or new partners attending a monthly meeting into future medical directors and board members is critical to the success of the group.  We require new partners to serve on our quality review committee (QRC) or frequent utilizers team.  This engages new partners in the group structure and cultivates interest in other clinical teams such as stroke, sepsis or trauma.  Encouraging new group members to participate in hiring committees and teaching opportunities can also be another way to engage new partners toward the corporate or educational structures of the group.  Once leaders emerge, sponsoring attendance at ACEP’s Medical Directors Academy or other educational opportunities can sharpen the administrative and leadership skills that may not be taught in residency. 

Many groups find that there is no problem filling the positions such as hiring chair, social chair or associate medical directors.  Despite the grooming and mentoring of new partners it may be difficult to find partners who can and are willing to take on the difficult administrative roles such as group president or medical director.  The time commitment and responsibility of a group president or medical director of a busy ED is much more than a monthly or weekly meeting and can be difficult to fill.   I can recall a few years ago during the Ebola scare when we thought we had a patient at 3am present to the ED with Ebola.  It was before we were able to complete all of the PPE training and I received a call at home.  I went into the hospital to help.  It turned out to be a false alarm.  Being present to answer questions and knowing who to call was valuable for the staff.   Ebola scares, provider concerns, state visits, and planning for meetings can result in a seven-day-a-week job despite the impression that meetings occur mostly during banking hours. 

The workload of upper-level administrative positions can create a leadership vacuum within groups.  There are a few tactics groups use to tackle this problem. Some, like ours, require everyone to participate in the group structure, which offloads the higher-level administrative positions and develops new leaders.  Other groups require a long partnership tract and offer clinical only tracts for physicians not interested in leadership positions.  I know of one group that hires every physician as a moonlighter.  Partnership requires not only clinical competency but also a five-year commitment, living close to the hospital, involvement in the local community and leadership position in the hospital or group.  This ensures that only those interested in leadership become partners.   This is one way to financially incentivize leadership positions.  Alternatively, some groups simply pay more for upper-level administration or give schedule preference to some leadership positions. 

Relevancy in independent emergency medicine practice requires more than showing up to work with a smile.  Clinical and financial viability in the current health care environment requires excellent CMS and patient experience scores and integration in the political structure of the health system and even the local professional societies.  There are certainly many ways to achieve this.  Please take the time to complete the independent group survey at  This will help us better quantify way groups pay for leadership positions.

Michael L. Becker, MD, FACEP
Immediate Past Chair, Democratic Group Practice Section

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