Beware the age extremes of ED leadership. The future of your group could hang in the balance.

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. No one seems to have noticed or objected to the double-dipping. Patient volumes have tripled over his tenure to more than 60,000 visits while the group continues to do their own billing. All of the physicians are independent contractors because that’s the way the more senior doctors want it. Dr. Doe attends all the meetings required of the medical director and says all the right things when approached with a problem, but people have begun to notice that nothing ever gets resolved and the department’s metrics continue to worsen.


It’s hard to write about your own. For me, that means the gray hairs, the oldest guys in the EM group, the guys who are feeling the fire in the furnace begin to wane. Many of us led our groups when we were younger purely on the strength of our determination. We now know that that isn’t enough to hold it all together. We’re worried about our portfolios’ value and its income producing potential in the midst of this unending recession and we’re fearful of the transition to living on a fixed income that’s likely to be much smaller than we had anticipated. We are all getting tired, some of us infirm. ‘Just a few more good income years,’ we say to ourselves.

Here’s the rub. Many of us gray hairs are still in positions of leadership, and the pre-retirement mindset has caused many to move into a posture of permanent defense, fighting a kind of holding action while we try to play out the clock. But leadership is about playing offense, and without that forward push – particularly in the face of today’s rapidly changing EM environment – we risk dooming our younger partners’ future by trying to maintain the status quo.

At best, this pre-retirement attitude manifests itself in a subtle obstructionism and the thwarting of new group strategic initiatives. Because we have been prescient leaders in the past, our partners assume that we see something they don’t, and so they defer to us. At worst, this attitude rears its ugly head as the leader who clings to a title and stipend but then schedules himself full-time clinically, providing no actual leadership. He reflects the group’s lack of consensus, rather than leading it to find consensus. As a result, the group fails to adapt, falling farther and farther behind the curve.

We old guys don’t do these things with malice aforethought; we are only human. But whatever the root, the result is simply poor leadership. Effective EM leadership requires optimism and a faith in the possibility of a better tomorrow. Contrary to the near fearlessness of our early careers, we how find ourselves saying things like ‘we tried that before and it didn’t work’ or ‘we’re too busy (doing things the old way) to take the time or spend the money planning for the future.’ We veto reinvestments in the practice because we know it will cost us current income and we probably won’t be around to see the longer term reward. To many of our partners it looks like nothing more than a heightened sense of caution. But it’s really as much about our anxiety about the loss of our identity as physicians and our increased fear of risk-taking. Almost imperceptibly we lose a degree of the selflessness that it takes to be an effective leader. We set ourselves up to leave the game with a whimper, rather than a bang.

But lest you think me too harsh, that I’m ageist or overly self-deprecating, let me explain a little something about young physicians. The old guys aren’t the only ones with the potential to lead our EM groups astray. On the other end of the age spectrum you’ve got something else to watch out for: the uninformed and overconfident. This leadership perspective comes from one or more of several possible misapprehensions. First, some partners, having never been held accountable for effective leadership, dismiss its value with comments like “How much skill does it take to sit in a meeting?” But effective leadership is the ability to deliver a targeted result within a defined time frame. To accomplish this in a consensus-driven organization like an EM group takes physician administrative time and a raft of other skills, some requiring a career to master. Meeting your administration’s targets for ED metrics has little to do with the clinical practice of EM and everything to do with effective leadership.

Second, some younger partners feel a visceral opposition to ramping up the organization’s practice management infrastructure to meet the demands of today’s bigger and more complex practices. Perhaps one of their residency program faculty members spoke negatively about the business side of EM, or maybe they once had a bad experience with a contract management group. Whatever the reason, these partners think anything resembling a business practice is evil. These partners are also quite often the ones who have trouble distinguishing between the needs of the practice and their own, and the ones who fail to check references or gather information about a problem and its potential solutions before making a hiring or business decision. They’re far more likely to trust their untutored seat-of-the pants judgment.

Age issues aside, there are three things that are necessary to secure an EM group’s future: (1) effective leadership, (2) strong relationships with administration and the medical staff, and (3) paying top dollar for the market the practice is in. The latter is to a great extent a product of the preceding two. A well-led department is an efficient department with such a high producer/low LWBS department having as much as a 25% revenue advantage over its opposite. Deep relationships with administration have the potential to produce hospital economic assistance that would be unheard of in their absence. Yet some partners will oppose investing in strategic planning, relationship and communications, and project management training for the group’s members as “unnecessary” costs. Most of the time what this really means is that they can’t see that the return on investment to the practice warrants some near term sacrifice of their own demands on the practice.

The day may be coming when not even leadership, relationships and how much you can pay will secure the future of the group’s contract(s). Sophisticated management information is now a basic requirement for a first tier EM group and this requires more practice re-investment than many groups want to make.  Accountable Care Organizations, bundled payments, managing down readmissions, or meeting the CMS ED performance metric de jour - all of these issues are too complex to be effectively managed without a sophisticated EM group IT infrastructure.

No matter the age of the leaders of your group, hopefully they will take a word of warning, against excessive risk as well as paralyzing caution. Our groups need bold, visionary, steady leaders who can keep organizations on track while growing in sophistication of practice. The very independence of your EM group depends on it.

Ron Hellstern, MD: Principal, Hospital Practice Consultants, LLC


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