Dr. Doe has been the medical director of his democratic group’s only contract for 27 years. He was board certified in family medicine but successfully took the ABEM exam and has maintained his board certification. He receives a substantial stipend from both the hospital and his group for filling this role but he has scheduled himself full-time clinically for the last three years because the group is chronically short-staffed.

In a democratic emergency medicine group, there are many ways to arrive at decisions, from command-and-control to consensus-building. What works best will depend on the character of your group, and what you hope to achieve.

In a recent emergency medicine listserv exchange several posters commented on the widespread abuse of emergency physicians made possible by their lack of due process “rights.” Perfectly innocent emergency physicians, nay even model citizens it was alleged, had been terminated on the spot purely on the whim of some grumpy hospital administrator with not a word of protest from the contract management group.

Healthcare reform threatens to usher in an era of complexity that could put small contract management groups at a distinct managerial disadvantage.