Tuesday, January 14, 2003

Fairness, Equity and Legacy—Just What do Emergency Physicians Deserve and Contribute?

At the recent ACEP annual meeting, the largest ever with a turnout of nearly 4000 emergency physicians and others, I heard a lot of discussion about “fairness for emergency physicians” and even participated in a lunchtime panel sponsored by the ACEP Section on Emergency Medicine Practice Management and Health Policy that considered the topic. One of the CME sessions included presentations by a representative of a practice management company and Joe Wood, M.D., current President of AAEM. Of great interest to me was the inclusion in the panel of Dr. Nancy Auer, a past-President of ACEP and emergency physician who is now Vice-President of Medical Affairs at Swedish Medical Center in Seattle.

The usual discussion and disagreements among proponents of differing staffing models was broadened by Dr. Auer’s inclusion as she spoke from the perspective of a hospital leader. I found her balanced presentation during which while discussing the various staffing models and the potential benefits or detriments those models delivered to emergency physicians, she kept her focus on the purpose of the ED: service to patients, communities—including the medical staff and the hospital itself. This discussion was quite valuable and in my experience somewhat novel in these debates—the audience seemed more comfortable with the discussion than did some of her fellow panelists. Her concern for the hospital’s relationship with its emergency physician staff was as clear as her insistence that excellent emergency physician clinicians were a necessary, but not sufficient condition for an excellent hospital emergency service. Obviously, her own career trajectory added power to the argument. She emphasized that patients who used the ED were coming to the hospital, whether on their own volition or referred by their own physician. She’s right and this is a key concept: Whether we like it or not, patients don’t come to see us, they come because their physician sent them or they chose the hospital for its reputation—of which we may be a part, but just a part.

At the lunch panel, one of the panelists spoke about his group’s incentive approach to compensation. Approximately 40% of the compensation earned by emergency physicians in this group was based entirely on individual billings. The more patients seen, the better the compensation for the individual. He felt rather strongly that this economic model optimized the clinical and service delivery in the ED. Furthermore, it was his contention that this approach contributed to the creation of equity in the group practice.

I have long been of two minds about financial incentives for workers of all types, not just physicians. My skepticism derives from my reading of Alfie Kohn’s Harvard Business Review piece, “Why Incentive Plans Cannot Work” from September 1993 and a follow-up HBR panel discussion in the November 1993 issue. (Readers who would like to read a related but simplified exposition on the same theme may view "For Best Results, Forget the Bonus." The HBR article is available for download or as a reprint for $6 by searching for it at http://harvardbusinessonline.hbsp.harvard.edu). In summary, quoting the blurb on the HBR site, “Kohn explains why rewards fail in a six-point framework: rewards do not motivate; they punish; they rupture relationships; they ignore reasons; they discourage risk taking; and finally, they undermine interest. Any manager thinking about a new incentive program—or attached to an old one—would do well to consider Kohn's argument. According to Kohn, incentives (or bribes) simply can't work in the workplace.” While I’m enamored of this argument, I don’t fully embrace it for I see that to an extent rewards do work—temporarily, even Kohn acknowledges this. Yet, it is because of this temporary character of the reinforcement induced by these financial incentives that I question their value in creating equity in the practice for emergency physicians.

In this context, I’m skeptical of my co-panelist’s view. His assertion that optimizing clinical and customer service by an incentivized physician staff strengthens the arms-length contractual relationship between the hospital and physician group, thereby creating continuing value in the relationship and shareholders’ equity in the contract for the members of the physician group. I see no intrinsic value creation, no true equity creation in the usual financial sense consequent to the contract itself. Where beyond the delivery of ongoing service to patients is there any value in the contractual relationship? This contractual relationship remains defined in purely economic terms in the contract between the parties. This is not an inherently bad or flawed arrangement, but it shouldn’t be construed as something it is not. It is not a relationship that creates shareholder equity. Where is the value if not in the delivery of physician services by the specific members of the group? What value has been created beyond the contractual relationship?

I suggest that emergency physicians might look to how they create value for the hospital as their means of creating equity through the practice of emergency medicine.

The hospital is the community-based entity that in all likelihood will transcend the lives of those who practice in it and lead it. Accordingly, it seems to me that the hospital is where we as emergency physicians should look to add value. While that value we create is measurable in part by the metrics of financial performance and the accursed quantitative customer satisfaction survey so beloved by some hospital administrators, the value we add is only partly measured by these metrics. What is the value to Swedish Medical Center of Dr. Auer’s leadership of the medical enterprise in her role of VP of Medical Affairs and didn’t the opportunity for that role arise directly from her contributions as an emergency physician and medical staff member?

As we participate more effectively and broadly in our hospital’s medical staff organizations, as our interests transcend our own narrow financial well-being and broaden to include the effectiveness of the hospital in the community we contribute to the creation of a legacy in the hospital and it is in this legacy that our equity lays.

Extrinsic motivation supplied by a bonus will elicit temporary adherence to the leaders’ dicta. As Alfie Kohn points out, “Loving what you do is a more powerful motivator than money.” I do understand that we work for money because that is how we support our family, and ourselves but don’t we really work as emergency physicians because we love our work and wish to contribute to something larger than ourselves? If so, that something larger, which all who live and work in the community “own” is truly the hospital, our workplace our locus of investment and equity and in its service to our neighbors and communities, our legacy.