I cringed when I saw the title “Pros and Cons: Does Size Matter?” and I kept the November 2015 ACEP Now issue hidden under the cover of other journals until I could force myself to read about democracy in emergency medicine. It was not as painful as I expected. Unfortunately, but not surprisingly, it did not answer the primary questions of the article: “What is the definition of “democracy?” and “How do you measure democracy?” I still don’t know from the article if size matters (for ED groups).

I finished residency in 1985, before we knew what democracy was. But we learned that some of us did not have it. I worked with a few groups and learned that each would portray the air of democracy. It did not take me long to decide what democracy meant to me. I wanted to be given respect for my medical decision making (when deserved) and treated as a financial partner. For most ED providers, the financial part of the equation dwarfs the clinical stuff. If the ED group had financial risk, I was OK being at risk. But the clinical aspect is really the most important. Find a job where you can work with docs who care about what they are doing, care about their patients, and care about their partners and you. Everything will follow after that. To be successful in this endeavor takes asking questions, being lucky, and taking time to see how your partners operate.

But that was not really the focus of the article. Here are my answers to the other questions about democracy. Does size matter? Probably not a lot, but it can. With both big and small groups, fairness is a trait that comes from top down, but it can be permutated into a mirage anywhere along the path without too much difficulty. Big groups have more paths from the top to you. Beware of smoke and mirrors from the top or along the way.

What is the definition of “democracy”? I have to say beauty is in the eye of the beholder. “We are a democratic group” sounds like the battle cry for the emergency physician employers of the past and future. The common nonmedical definition of democracy portends that it is a system of government controlled by its members, usually by voting. If there is equitable pay, scheduling, and open communication to and from members of the group, I don’t really need to have a vote. To me, a democratic ED group is a group of emergency providers united to care for a common group of patients in an organization that allows open communication, open books, equitable pay, fair scheduling, and equity if equity is earned.