For decades, the concepts of democracy and democratic group practice have been held as the standard to strive for in emergency medicine. As democracy is akin to motherhood and apple pie, these concepts are accepted today, perhaps, just as they were decades ago. However, with the evolving landscape of health care, is it time to revisit these concepts? Is democracy a group structure or an ideal? Democracy can provide an opportunity to participate in group decisions and control one’s own destiny (to a certain extent), but democracy means that, on occasion, you may not get what you want if you are in the minority. Is democracy truly what emergency physicians want, or has fair and equitable treatment become the practical definition of “democracy”? In this three-part series, EM leaders from different walks of life will weigh in on the following questions. Read Part 2.
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ACEP Now: Vol 34 – No 10 – October 2015—Kevin M. Klauer, DO, EJD, FACEP
Moderator
Ricardo Martinez, MD, FACEP, chief medical officer for North Highland Worldwide Consulting and assistant professor of emergency medicine at Emory University in Atlanta
Participants
Savoy Brummer, MD, FACEP, vice president of practice development at CEP America in Belleville, Illinois, and chair of the ACEP Democratic Group Section
Wesley Fields, MD, FACEP, past chair and the most senior member of the Board of Directors of CEP America in Emeryville, California
Nicholas J. Jouriles, MD, FACEP, president of General Emergency Medical Specialist Incorporated, a single-hospital group in Akron, Ohio
Lynn Massingale, MD, FACEP, executive chairman of TeamHealth in Knoxville, Tennessee
Dighton C. Packard, MD, FACEP, chief medical officer of EmCare in Dallas
RM: So let me go with our first question: what is the definition of “democracy”?
WF: Well, I think this is very perspective-driven, and I’ll start with one that I don’t necessarily subscribe to but I think is common with emergency medicine, in particular in a lot of residency programs, and probably supported by the American Academy of Emergency Medicine. Some folks in emergency medicine believe in an ideal or aspiration that’s based partly on the idea that emergency medicine can be practiced privately in the same sense you can have a private practice, such as dermatology or something else that’s not hospital-based, and that beyond that, all rights and privileges that can be assigned to other medical specialties need to be attributable and available for emergency physicians as well. I think that some folks believe that to be an attainable goal or a reality in our present world, but all of us have real-life experiences that demonstrate how tough it is to get close to that ideal.
4 Responses to “Emergency Medicine Leaders Discuss Pros, Cons of Democratic Group Practices”
October 25, 2015
ED PhysicianTo Dr. Packards point.. I don’t think it is fair, logical, or even reasonable to conclude that what EMCARE is doing is “democratic”. I certainly think there are countless examples of completely unfair actions that EMCARE has taken against ED Physicians. I specifically have several, which I think if Dr. Packard new he would rectify. There in lies the problem.. EMCARE is so big that terrible atrocities are being done against ED Physicians and the people at the top don’t even know. In a democratic group, because it is smaller and the power is distributed these terrible actions are avoided. The profession of emergency medicine is being destroyed by this type of unaccountable behavior.
I hope Dr. Packard is interested in what is happening at a local level within EMCARE!!
October 25, 2015
John ShermanI think it unfortunate that the panel is mainly folk who are in the upper positions of apparently non-democratic groups. I get from the above discussions a paternalistic view: some people at the top know how to run the business better and that is the best way for it. It is then rationalized into the social darwinism framework of that is what is needed for groups/companies to survive. Rather Ayn Rand-ish. I also get the sense that a couple of the responses were being obviously obtuse with the sentiment that ‘some people want to do more of the administrative work and so it does not come out evenly’ – most ER doctors are smarter than that and know that administrative work is necessary and will proportion payment to those who are doing the “back office” work of the group. A good part of the chagrin from the “pit doctors” in a non-democratic group is over-valuing the administrative tasks compared to clinical work, to the point of the administrative level people in the organization getting considerable-fold higher incomes. That is the common “business-model” for corporations, but should it be that way for a group of professionals? I am a contractor for TeamHealth, and I would say that I have no particular say in anything the group does and know that a considerable portion of my revenue that I generate goes to a lot of administrative overhead that does not have transparent value.
I think the virtues of a democratic practice are good and could be strived for and incorporated into even “corporate model” groups of doctors.
October 26, 2015
Bill BassMany of us think that democracy is the fairest form of governance of any organization. Watch the video regarding democracy vs a republic ( https://www.youtube.com/watch?v=JdS6fyUIklIto ) to really understand democracy.
The complexities of medical practice with it’s insurance, government, and regulatory burdens make solo practice almost impossible. A group that manages billing, insurance, malpractice insurance, pension plan, health insurance, CME, and scheduling well, certainly deserves a fair profit. That profit should be openly available to all group members a to see and invest in if they so chose. If you can find a group this open, you should join it.
Bill Bass, M.D.
November 5, 2015
Dominic Bagnoli, MD - CEO, USACSAs the co-founder and current CEO of one of the largest democratic EM groups in the country, I am acutely interested in this discussion and the comments that have followed. Being a democratic practice has been the gold standard in our specialty for decades and that hasn’t changed but as the discussion clearly highlights, there isn’t a consensus opinion as to what constitutes a democratic practice and for many, democracy is in the eye of the beholder. Realizing that there are many different perspectives of democracy, it occurs to me that we are using the wrong standard to judge an ideal EM practice. From my perspective, the real issue is equity and ownership. Do the practicing physicians own the practice? Do they have a path to ownership? What exactly do they own? I believe being an owner is the real difference maker. Everyone takes better care of something they own. Have you ever washed your rental car? Additionally, democratic and physician-owned groups will need more support and resources than ever to succeed in the progressively complex healthcare environment. All groups will need capital for investments in processes, infrastructure and technology in order to deliver better, more efficient care. Hospitals will also require support and partnership with world-class business leadership. It will be increasingly difficult, if not impossible, for smaller EM groups to access either of those. We are building a large EM group committed to physician equity and shared ownership for all of our members. Having a democratic vote is important, but it is not a substitute for being an actual owner of the practice.