RM: You want to expand on that?
LM: Well, first off, I don’t think there are many groups that meet all the criteria that Savoy just recited. I’m not quarreling with them at all. I just don’t think there are many groups like that in any specialty and certainly not in emergency medicine. Second, with the pace of change and the challenges that face all of us these days, I just respectfully question whether it’s a practical model for “running a railroad,” if you will. I think if you take that to its logical extreme, it means that each person has equal responsibility for everything that the organization does, legally, financially, etc. By and large in groups, even the ones that have one person, one vote, my experience has been that the work is never equal and the level of commitment to accountability and responsibility is never equal. There are pretty big differences even within groups that are largely or entirely democratic by even that strict definition.
RM: Great. Who hasn’t weighed in here? Dighton?
DP: I think we need to be definitive about what exactly we’re trying to define here because Savoy clearly enunciated what ACEP’s policy is and that’s what a democratic group is. What does “democracy” mean? We may be talking about two different definitions there. I think I would lean more toward, when you say what does “democracy” mean, what it means to individual physicians. When a doc is working in the emergency department, does he feel or she feel like that she’s being treated fair or equitably? Does she have a voice about what goes on in that department? I feel like, more often than not, that’s what they would define as “democracy” rather than “I have ownership and I’m responsible for everything that we do.” What I’m finding is—and I freely admit that I’m not sure that I’m the oldest person on the call, but some of us have been around a lot longer than others—that I’ve seen this change. I know that when we started out, we very much wanted to have our own shop. We wanted an independent practice within the hospital. I think Wes, and to some extent Lynn, has already said that this is becoming intensely difficult to do, just like we’ve seen many of our fellow independent practitioners outside the hospital coalesce together in large groups for very obvious reasons to them. I think that’s what’s happening to hospital-based groups as well. It’s becoming very difficult to
“Fairly” is situational. What’s fair in one group is not fair in another. I think as long as each individual member is treated fairly within their own group, that’s what should count. —Nicholas J. Jouriles, MD, FACEP
Clearly there is confusion, and many times that type of confusion is present because there are groups that are trying to confuse the term for their own purposes. It has been very, very clearly stated, by both AAEM and ACEP, what the tenants of a democratic group are about. —Savoy Brummer, MD, FACEP
The important question is whether or not the democratic practice model is clearly the best way to deliver care on behalf of populations or if it’s really a boutique kind of activity that can only happen in increasingly rare circumstances. —Wesley Fields, MD, FACEP
practice independently. The regulatory, bureaucratic requirements and hospital-based requirements are making it much more difficult to do that. Even if one was to agree that it was ideal, one hospital, one group, purely democratic practice, according to ACEP’s definition, I think it’s very, very difficult to accomplish that in today’s world. Much less, when you deal with systems of hospitals, then it becomes even more complicated. Democratic group, well, ACEP has it defined it. I guess I could argue with one or two words, but I think it’s more important to me what my doctors feel about it. My doctors feel that they’re being treated fairly both by my group and by the hospital. To some extent, I see that as part of my job to make sure that happens.