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MEDICINE NEWS

September 2006

VOL XXVIII, No. 9 Editorial Board: Chairman James R. Roberts, MD Mercy Catholic Medical Center & Drexel University College of Medicine Philadelphia, PA

Viewpoint

Greater than the Sum of its Parts

By Ronald A. Hellstern, MD

tion, I should first be able to answer these two. eing retired from 30 years of emergency medicine clinical practice and proA successful group has skillful group leadership, a group culture of viding management assistance to independent emergency medicine groups treating each other and all those conas I do now, I’ve had the privilege of looking inside many groups and observing nected to the practice with dignity, compassion, and respect (in a word, that every successful and secure independent emergency medicine group is integrity), coupled with equal measures always greater than the sum of its parts. of discipline and accountability, and a group vision that is greater than just This observation stands in some certification are admirable achieveworking the shifts and maximizing contrast to the attitude of many ments, but today they are really no more take-home pay. younger emergency physicians who than the basic price of admission to the No matter the emergency medicine have been led to believe (erroneously, I specialty, and so guarangroup composition or think) that they are the practice, the tee nothing but an ownership model, if the practice is them, and everything other opportunity to attempt leadership doesn’t skillthan working the shifts and maximizing to make a group pracfully take charge, expect take-home pay is either superfluous or tice work, regardless of and insist on integrity, parasitic. The trouble with this point of its structure. create and enroll the view is that, if it were true, an emerSo what are the group’s members in a gency medicine practice could never be essential attributes of a future vision of themmore than just equal to the sum of its successful and secure selves that they can parts, less some irreducible measure of independent emergency believe in and aspire to, parasitic drag, and that only when all of medicine group? And and maintain discipline the group’s members were performing how should a leader go and order, the group will optimally. about leading the group not be successful and The key to independent group suctoward achieving them? secure. I have come to cess and security goes far beyond the These questions are of this conclusion gradually Dr. Ronald A. Hellstern group member’s credentials (residency more than passing interover years of observing trained and board certified in emerest to me because I regwhat the majority of the gency medicine) and the group’s strucularly go on the road masquerading as members of every emergency medicine ture (democratic and equal). The fact an incredibly smart emergency medigroup communicate with their words that groups with these characteristics cine practice management consultant and actions about what’s most imporlose their contracts suggests that perfrom Dallas, replete with power tie and tant to them: ■ Schedule parity. haps group success and security is not laptop, spinning my Excel pivot tables, ■ Fewer meetings, e-mails, and primarily a question of group composiand doing my best to show I have all the requests to do things differently. tion or ownership structure. Emergency right answers. But surely if I am sup■ A say in the organization and opermedicine residency training and board posed to be able to answer any quesation of the workplace and the running of the group, but only when they feel like it. Continuing Medical Education in EMN ■ A little more help from the nurses, n this and every issue, Emergency Medicine News offers two CME activiancillary departments, and the onties: 1) InFocus, the clinical evidence-based column written each month by call medical staff. James R. Roberts, MD, and 2) Learning to Live with the LLSA, a review of the ■ A little less help from the governAmerican Board of Emergency Medicine’s Lifelong Learning Self-Assessment ment, the JCAHO, and other medreading list by Daniel K. Mullin, MD. dling do-gooders. Target Audience Statements: The InFocus CME activity in Emergency ■ The best possible compensation Medicine News is intended for emergency physicians with an interest in the package. diagnosis and treatment of various disease processes commonly seen in emerleadership influence, it isn’t Without gency departments, with special emphasis on evidence-based medicine. The difficult to imagine how a group of indiLearning to Live with the LLSA CME activity in Emergency Medicine News is viduals with a limited outlook might fail intended for emergency physicians with an interest in studying for the annual view of the to appreciate the hospital’s American Board of Emergency Medicine’s Lifelong Learning and Self-Assessimportance of ED throughput times, ment examination. resource utilization, admission rates, Accreditation Statement: Lippincott Continuing Medical Education Instiand patient satisfaction scores, or of initute, Inc., is accredited by the Accreditation Council for Continuing Medical tiatives like helping to staff an observaEducation to provide medical education to physicians. tion unit or start a hospitalist program if InFocus Credit Designation Statement: Lippincott Continuing Medical requested to do so. These emergency Education Institute, Inc., designates this educational activity for a maximum physicians aren’t bad people; they are of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit comjust people trying to be the best practimensurate with the extent of their participation in the activities. tioners they can be in a very demanding Learning to Live with the LLSA Credit Designation Statement: Lippincott profession amid all the other pressures Continuing Medical Education Institute, Inc., designates this educational

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activity for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should only claim credit commensurate with the extent of their participation in the activities.

InFocus CME begins on p. 26 LLSA CME begins on p. 14

Dr. Hellstern is the vice president of physician executive development with PSR in Dallas. Continued on next page

William G. Barsan, MD University of Michigan Ann Arbor, MI William Brady, MD University of Virginia School of Medicine Charlottesville, VA W. Richard Bukata, MD San Gabriel (CA)Valley Medical Center Theodore Chan, MD University of California School of Medicine San Diego, CA Steven J. Davidson, MD Maimonides Medical Center Brooklyn, NY Timothy B. Erickson, MD University of Illinois Chicago, IL Glenn Fink, MD St. Barnabas Hospital Livingston, NJ Jonathan Glauser, MD Case Western Reserve University Cleveland, OH Lewis Goldfrank, MD Bellevue Hospital/NYU Medical Center New York, NY Richard Hamilton, MD Drexel University College of Medicine Philadelphia, PA Richard Harrigan, MD Temple University Hospital and School of Medicine Philadelphia, PA Katherine Heilpern, MD Emory University School of Medicine Atlanta, GA Jerome Hoffman, MD UCLA School of Medicine Los Angeles, CA Lawrence Isaacs, MD Temple University School of Medicine Philadelphia, PA David Karras, MD Temple University School of Medicine Philadelphia, PA

Brent R. King, MD The University of Texas Houston Medical School Houston, TX Edwin Leap, MD Oconee Memorial Hospital Seneca, SC Robert M. McNamara, MD Temple University Philadelphia, PA Ash Nashed, MD Columbia University College of Physicians and Surgeons New York, NY Stephen Playe, MD Baystate Medical Center Springfield, MD Jeffrey Selevan, MD Southern California Permanente Medical Group Pasadena, CA Andrew Schiller, MD St. Barnabas Medical Center Livingston, NJ Earl Siegel, PharmD Drug & Poison Information Center Cincinnati, OH David A. Talan, MD UCLA School of Medicine Sylmar, CA Ellen Taliaferro, MD The University of Texas Southwestern Medical Center Dallas, TX Peter Viccellio, MD SUNY School of Medicine Stony Brook, NY David Wagner, MD Drexel University College of Medicine Philadelphia, PA Ron Walls, MD Brigham and Women’s Hospital & Harvard School of Medicine Boston, MA Shari J. Welch, MD Salt Lake City, UT

Published monthly by Lippincott Williams & Wilkins. Editor: Lisa Hoffman Art Director: Kathleen Giarrano Associate Director of Production: Barbara Nakahara Desktop Manager: Peter Castro Manager of Circulation: Deborah Benward Editorial Assistant: Erin Bascom Circulation/Production Assistant: Fred Rella Group Editor: Serena Stockwell Executive Director of Continuing Education: Jay Magrann Publisher: Ken Senerth Vice President, Executive Publisher: Ray Thibodeau Director of Advertising Sales: Mike Guire Manager of Advertising Sales: Martha McGarity Advertising Representatives: Classified Advertising: Breuning Nagle Associates Melissa Moody 58 Pine Street 351 W. Camden St. New Canaan, CT 06840 Baltimore, MD 21201 (800)269-4339 James L. Nagle (410)528-4452 (fax) (203)801-0055 (203)801-0011 (fax) [email protected] James F. Breuning (609)397-5522 (203)801-0011 (fax) [email protected] Emergency Medicine News (ISSN 1054-0725) is published monthly by Lippincott Williams & Wilkins at 16522 Hunters Green Parkway, Hagerstown, MD 21740. Editorial, business, and production offices located at 333 Seventh Ave., 19th Fl., New York, NY 10001; (646)674-6544; fax: (646)674-6500; [email protected]. Printed in the USA. ©Copyright 2006 by Lippincott Williams & Wilkins. Periodical postage rates paid at Hagerstown, MD, and at additional mailing offices. Physicians who are registered with AMA/AOA as having a primary or secondary specialty related to emergency medicine, as well as SEMPA members (within the U.S.), are eligible for a free subscription. To place an order, cancel a subscription, change your address, or for other subscription services, please call (800)430-5450, fax to (800)383-1781, or send an e-mail to [email protected]. (Please remember to include your current mailing address and specialty.) POSTMASTER: Send address changes to: Emergency Medicine News, 2340 River Rd., Ste 408, Des Plaines, IL 60019-9883. No part of this publication may be reproduced without the written permission of the publisher. The appearance of advertising in Emergency Medicine News does not constitute on the part of Lippincott Williams & Wilkins a guarantee or endorsement of the quality or value of the advertised products or services or of the claims made for them by the advertisers. The authors, editor, and publisher have tried to ensure that the information, including drug selections and dosages, in this publication meet current recommendations. Readers are urged, however, to check the package insert of each drug for changes in indications and dosage and for added warnings and precautions. The authors, editor, and publisher are not responsible for any errors or omissions or for consequences from application of the information in this publication, which remains the professional responsibility of the practitioner.

Viewpoint

EM GROUP LEADERSHIP Continued from previous page

in their lives. And because the composition of every emergency medicine group is pretty much the same these days, the wise leader doesn’t focus on putting together a “better” group of people but on how to effectively inspire and lead the ones already present. The most accomplished independent emergency medicine group leaders appear to me to first succeed in establishing a clear distinction between the practice of emergency medicine and the conduct of the practice, where others do not. Properly trained and supported emergency physicians practicing high quality, patient-pleasing emergency medicine are the product of the practice, but not The Practice. The widget is not the company producing it, and the company is not the widget. One exists to enable and support the delivery of the other. The neglect of the practice eventually leads to no practice, just as the neglect of the company eventually leads to no widgets.

‘Start developing your group’s leadership before the contract management group Grim Reaper comes calling.’

The practice must be an entity unto itself, establishing the context in which high quality emergency medicine gets delivered, and providing continuity to the group, existing as it does both before and after the tenure of its individual members. The practice establishes the organizational environment within which quality and standards are maintained, the future vision is articulated and hopefully achieved, new members are brought into it, older members are transitioned out of it, and long-term collectively shared practice obligations are met. The failure to establish this key distinction first makes it subsequently almost impossible to satisfactorily resolve the inherent conflict between the needs of the practice and the needs of the individual members of the group. The leader’s most important job is to lead the group to consensus regarding a future vision of itself that is larger than the day-to-day practice of emergency medicine, and then holding the group members accountable for words and actions that are consistent with achieving it. It is this commitment to a vision of the practice that provides the context for the group doing the things that will

enable it to become greater than the sum of its parts, things like moderating individual expectations in deference to group well-being, investing in leadership and leadership development, and managing the group from a long-term rather than a short-term perspective. The best leaders succeed in leading the group to this vision in such a way that the group members own it and believe it was their idea to begin with. Some elements that are common to most emergency medicine group vision statements are integrity, quality, excellence,

and respect for individual rights and responsibilities. Others might be hospital partnership, group growth and expansion, or a broader commitment to emergency medicine in the community through such things as EMS outreach, urgent care centers, or staffing satellite hospital EDs. These are all things to believe in for a career, so that when the challenge and excitement of emergency medicine practice begins to wane between eight and 10 years into it, when the cynicism about the social causes of so many ED visits

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(and one’s inability to alter them) starts to creep in, and when the future sometimes looks like a long stretch of numbing repetition layered onto a foundation of chronic sleep disturbance, it is this larger vision that keeps us in the game. Without this vision, the temptation to see ourselves as an unappreciated and abused minority is great because there is, of course, some evidence for it, but it is a very dangerous point of view from which to try to do business with a hospital. Hospital CEOs want strong group Continued on next page

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September 2006

EM GROUP LEADERSHIP Continued from previous page

leadership and an administratively competent, upbeat, can-do emergency medicine group, not a bunch of whiners who can’t even manage themselves. For the practice to become greater than the sum of its parts, it must deliver on most if not all of the following: ■ Valuing and investing in the leadership of the practice. ■ Building and maintaining relationship bridges with key nursing, medical, and hospital administrative personnel. People do business first with people they know and like; competence comes second. But, of course, everyone would prefer both if possible. But the point is that unassailable clinical competence does not trump the need for warm and cooperative personal relationships in conducting the business and maintaining the group’s contract. ■ Being instantly responsive to departmental problems such as peak load crises, interpersonal conflicts, and patient and medical staff complaints and to new leadership initiatives such as staffing the hospital’s urgent care centers or starting a hospitalist program. If the group can’t fill these needs for the hospital, there are many other groups who can and will. ■ Paying close attention to patient satisfaction and being able to effectively address recurring deficiencies, even those among the group’s partners. ■ Delivering a credible risk management/performance improvement program. ■ Maintaining an effective EMS liaison. ■ Regularly investing in the group’s support staff through in-services, collaborative protocol development, and social event participation, and routinely soliciting their input about your group’s deficiencies. ■ Maintaining a presence at key hospital and medical staff meetings where the absence of representation too often leads to emergency medicine group disadvantage or being blindsided. ■ Providing for competent and costeffective business management. Both the successes and failures of the emergency medicine group in its business management are magnified two to three times on the hospital facility side. If the emergency medicine group can deliver and document one more dollar of medical service, that typically means three more dollars for the hospital. Unaddressed, emergency medicine practice business inefficiencies can be lethal if first brought to the light of day by the hospital.

Viewpoint

■ Being able to effectively govern

yourself and discipline your own. EDs function poorly and produce a lot of staff upset when every clinician is left free to decide emergency medicine group policy or how his patients will be managed. Someone must have the authority to impose the discipline of speaking with a single voice on all of the group’s members. A frequently encountered emergency medicine group self-deception is to

attempt to address these tasks by parceling them out among the group’s members or, worse yet, rotating responsibility for them. This approach panders to egalitarianism at the expense of the practice. It implies that there is no such thing as leadership and administrative aptitude, knowledge, and skill. And it usually results in the things we’ve listed not getting done by individuals who didn’t have the interest or skills to do them in the first place. In many cases, non-physicians can do these tasks better and at less cost

than physicians, but when you haven’t first established the distinction between the things the practice should rightfully pay for and the owner’s wallet, the short-term decision to “keep the money in the practice” somehow seems to make sense even when it doesn’t. No well run business would ever take its only revenue-generating resource (capable of generating $500 to $700 per hour or more in billings), and employ it doing a $25 per hour administrative job, but independent emergency medicine practices do this all the time. Unless the

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Viewpoint

group’s leadership can intervene in such penny-wise and pound-foolish decisionmaking, the group will not be successful and secure. In medical practices as in life, 10 percent of the people accomplish 90 percent of the leadership tasks in most group endeavors. Not all of us are interested in or have the aptitude to be the leader, but someone has to be in charge and accountable for things to get done reliably. To paraphrase the tragedy of the commons, when everyone’s in charge in the independent

emergency medicine group, no one is in charge. Shared accountability never works; the blame when something doesn’t get done just gets passed around the circle. Good leaders, as W. Edwards Deming said, are made, not born (“I’ve never met a natural,” were his words), and the process of making a good emergency medicine group leader typically takes years. Board certification and productivity-driven compensation can easily ensure that individual clinical practice benefit is proportionate to

credentials and ability, but good leadership and administrative skills are incremental to emergency medicine clinical competence and productivity, and they should be valued and compensated accordingly. Any emergency physician who thinks emergency medicine group leadership and administration (which often includes being continuously on-call) are easier than staffing a shift has simply never experienced the responsibilities of this role when correctly performed. So if emergency medicine group suc-

cess and security are important to you, I recommend a reassessment of your group’s leadership and the members’ willingness to follow it. If you don’t have a strong leader, you might want to consider recruiting one. One way to begin investing in the leadership you have is to send those group members who are interested and capable to ACEP’s ED Directors Academy. It’s always, always too late to start developing your group’s leadership when the contract management group Grim Reaper comes calling.

LETTERS Continued from page 3 of residency, most physicians I have talked to about this issue would agree with Dr. Jerome Hoffman’s statement made during an article review session for Audio Digests Emergency Medicine (1997;14[19]): “It’s sort of crazy that we have a system [residency training] where we mostly teach ourselves. We do a lot of teaching ourselves…. This just sort of points out that in residency we don’t do such a good job of really supervising our residents. I think we all know that.” Is the community practice of emergency medicine really unsupervised? The second fiction that Swensen et al maintain is that experience gained during community practice of EM is unsupervised. As an EP who has practiced for 16 years in the community setting, I am qualified to give testimony about the validity of this claim. I will try to explain how supervision works outside the hallowed halls of academe, where adequate “academic supervision” is still an open question. Simply put, job security is the measure of success for community EPs. The quality of an EP largely depends on the perception of their performance by the customers (a more difficult standard to achieve than the actual objective clinical performance). Both clinical and service performances are intensely monitored in the community setting by multiple parties with vested interests. ED nurses are the first line of supervision. If the EP is rude to staff, slow to move patients, or delays responding to the nurse’s beck and call, then the nurses become uncomfortable working with Dr. So-and-So. Nurses in the community setting have the political power to have administration remove the EP from the schedule. The second line of supervision is composed of attendings and consultants. They are promptly available by phone, and must come in to help stabilize patients per EMTALA mandate if necessary. Community-based attendings have an ownership mentality and take an intense interest in care of their patients. Feedback is routinely given through peer review, verbal follow-up, etc. Space does not permit me to go into more detail about how the army of de facto supervisors (ED medical directors, respiratory therapy, paramedics, registration, medical records, regional directors, contract managers, department heads, hospital