Sunday, October 14, 2001

Are You a Professional or Merely an Economic Wo/Man?

Making a profit from emergency medicine whether for individual or corporate benefit is neither unethical nor illegal. Yet, if as emergency physicians we don’t invest in the communities we serve and their institutions, have we behaved ethically? Can we live our professional lives extracting profits and maximizing only our own well-being? Aspiring to ownership of our practice and maintaining open financial books with physician control of our fee revenue is the behavior of an economic wo/man, but are these sufficient aspirations for emergency physicians? Where is the investment in community and hospital, both entities which will outlive any individual physician and which enable our practice in the first place?

The current debate speaks regularly to physician entitlement through its emphasis on the benefits or detriments to the emergency physician of the particular business model through which we organize to earn our living. With varying degrees of explicitness, proponents of these various business arrangements presume that revenue in excess of expense will accrue to either the corporation or the individual. Rarely do proponents of any particular business arrangement address our concomitant responsibility for service to our community and its institutions—our hospital—with which we are inextricably bound in partnership. Mostly in our work and through our professional societies we’ve become caught up in the business of medicine and have become neglectful of the ideals that first brought us to the profession.

More than a decade ago, George Lundberg then Editor of JAMA wrote of the problem in "Countdown to millennium—balancing the professionalism and business of medicine. Medicine’s Rocking Horse." (JAMA 263(1):86-719; Jan 5, 1990). Later follow-ups including those after the AMA’s debacle in contracting with Sunbeam in 1997-98 have seemingly served only as markers of medicine’s fall as a respected profession. While our professional societies proclaim their social concern through their political lobbying and attendant efforts on behalf of the profession, few of our individual practices look beyond mere business arrangements to wider professional responsibilities.

I come from an academic tradition and practice in a community-based tertiary teaching hospital, so I’ll acknowledge my idealism. Yet in these times we all must be practical. James C. Robinson in "The End of Managed Care," (JAMA 285(20):2622-2628; May 23/30, 2001) convincingly documented a shift to the consumer as the locus of health care priority setting, driven by widespread skepticism of governmental, corporate and professional (emphasis added) dominance. Despite what you may believe, patients don’t come to your ED to see you, most come to your ED because that is where their private physician tells them to go. In communities where primary care is otherwise unavailable, patients come because your ED is where your community-based hospital makes primary care available. A few patients come because your hospital operates a trauma, pediatric or cardiac specialty center. But the patients come to the hospital, not to you.

A year ago in describing a new paradigm for physician leadership "Leading Beyond the Bottom Line" I wrote about physician leaders striving for an optimum balance among the competing goods of financial health, patient care, employee well-being, and community commitment. In our excessive focus on our own financial health through delivery of patient care services we’ve neglected our communities and the institutions that do and will serve them. We’re training a generation of residents and novice practitioners of emergency medicine to set aside the idealism that brought them to medicine. We’ve tipped the balance to the business of medicine as Lundberg feared and we are harvesting the bitter practice environment that Robinson predicts. As leaders we have a responsibility to leaven the practicalities of emergency medicine practice today with the larger professional goal of service.

Yet, most emergency physician practice business models compensate clinical staff at a higher hourly rate than front line physician managers, those physicians with locally based direct operational administrative and process improvement responsibility in the ED. Even though an effective physician-manager enables the clinical staffs’ delivery of improved care and service. Some practices deliberately restrict the funding available for such non-clinical work; subjecting such funding to a vote within the practice is sure to limit support for such investment as long-term strategic planning takes a backseat to more immediate financial self-interest. Such a preoccupation further estranges emergency physicians from their hospital-based colleagues in nursing and administration and neglects the community-at-large.

Some practices and practitioners do reinvest in their hospitals and communities. Whether taking a public health perspective of emergency medicine and addressing under-served communities or engaging systematically in community-based education programs these practices commit time and money in addressing concerns raised by the community they serve. These same and other practices participate in hospital based process redesign so that patient flow improves thereby reducing ED overcrowding. The benefits for the practice are manifold as patients and staff are less harried and hospital administrators can apply scarce capital funds to other institutional priorities. This demonstration of good hospital citizenship can only redound to the benefit of the practice. Learning and professional development opportunities for physicians abound in these groups because this work requires the efforts of more than a single physician leader.

W. Edwards Deming remarked that great leaders almost always get great results, but that was not enough. He asserted that it was the responsibility of great leaders to build systems so that average leaders could attain great results. Without reinvestment by our practices in our hospitals and the emergency physicians who would be our future leaders how will we attain great results (improvements in quality of service and care) for our patients, hospitals and communities in the future?

A comfortable, secure livelihood in a professionally rewarding practice is an accomplishment for all emergency physicians to earn—we’re not entitled to it. Earning that livelihood entails more than delivering good patient care; it requires investment—whether personally or through our practice—in our hospital organization and the community it and we serve.

Doctor William Kissick, one of my professors at Wharton, taught in his health care policy class, "Where you stand (on an issue) depends upon where you sit." So let me disclose that I’m a salaried employee of Maimonides Medical Center, a large tertiary care teaching hospital, where I lead both the clinical and operational aspects of a ~78,000 visit/year ED and its associated ambulance service. I belong to both ACEP and AAEM among other organizations. Given the array of my responsibilities, in the past two years I have worked very few clinical hours—just enough to allow me to examine for ABEM. I’m quite ambivalent about this withdrawal from the "pit," yet I enjoy my managerial role immensely, even as I mourn the clinician I used to be. Hospital employed by contract, our emergency physicians are accountable to me and receive guaranteed base pay and benefits. Additional earnings based on a variety of measures of economic, academic, team-building and less objective measures of productivity and effectiveness have been paid out semi-annually for six years as of this writing. Physician contracts have no restrictive covenants or non-compete clauses but do require that physicians relinquish most of the usual medical staff due process rights; although, they have due process rights built into the contract--the same due process rights I have with the hospital, our mutual employer. All department and practice finances are open to all emergency physicians. I focus my daily work on team building and system building so that our hospital and community may rely on continuously improving service and care.

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