Strategies For Cutting Back: Group Policy Change

crispydoc Uncategorized 12 Comments

But we’ve always done it this way!

Medicine is a conservative profession, where change is viewed with suspicion and the reason, “But we’ve always done it this way!” is as unquestionable as, “I’m the mommy, that’s why!” was in childhood.

(Incidentally, the latter was the bumper sticker on the station wagon that served as my first car, which made meeting girls as a 16 year old uniquely challenging. A story for another time).

Owning your business means you get to make the rules.

Our ED group is a unicorn, a single-hospital democratic group in community practice. We run our own business, with commensurate risks and rewards. After a period of explicitly defined sweat equity, new members get equal equity standing with an equal vote.

Like medicine anywhere, we had certain traditions that had developed over time.

Our culture was one of givers – when someone needed to swap out of a shift, you helped if you could. When the department was getting killed, you stayed a couple of hours late to help your friends.

During a period of chronic under-staffing several years ago, this culture of giving was stressed beyond capacity, because everyone was working more than they wanted to work.

Happy moments, like a friend giving birth, turned into cause for resentment – one person’s joy transformed into your pain. Tradition dictated that the extra shifts during leaves of absence were simply divided equally among all group members.

Assuming my family was like Mad Men made for a mad wife

Perhaps this model worked when every physician was part of a nuclear family, with a standard division of labor: one breadwinner who worked in medicine and a stay-at-home partner who ran the household, raised the children and absorbed any unexpected shocks to family life that the physician’s career might bring.

The implicit assumption was that everyone either had (or had best rapidly develop) a system at home to absorb the impact, as everyone was expected to “step up.”

This assumption was not valid for my family. My wife is a physician who works part-time, an entrepreneur who runs a consulting business, and a logistician extraordinaire who handles most child and household scheduling.

She grew understandably resentful of my job at having to pick up the slack for my group’s under-staffing. She made a cogent argument that she was paying a penalty by virtue of having been born with ovaries.

Many of these things are not like the others

As I looked around at our group, I noticed that ours was not the only non-traditional medical family. There were dual-earner families, single parents, and men and women who took a more hands-on approach to parenting than prior generations of physicians. There were families who supported elderly parents.

Our docs also participated in emergency medical services, local residency programs, the county fire department, tactical medicine for the local SWAT team, urban search and rescue, the hospital foundation and regional disaster preparedness. Their time to pursue these interests was being squeezed as well.

We felt a pervasive sense of learned helplessness compounded by martyrdom in medicine. Medicine was allowed to demand your attention above all other life priorities. If your medical career did not entail suffering, you must be doing it wrong.

[Digression for purpose of illustration: During our annual residency retreat, we put on a performance meant as a good-natured ribbing for the faculty we worked with. A spoof of the quiz show Jeopardy! asked the total number of spouses, past and present, among three tenured faculty: The correct answer was 9.]

Changing an institution from within

This was a difficult time in my life, but unhappiness can be a great motivator.

I’d always believed the most effective way to change a system is incrementally, by revolution from within.

My wife and I began brainstorming an alternate, ideal version of a more accommodating medical career.

Know your audience

I first assessed the voting demographic. Our group consisted of:

  • One third older traditionalists, whose lives conformed well with the current system.
  • One third mid-career docs closer to my age, many of whom had young families placing increasing demands on their time.
  • One third young guns, who were hungry to earn and pay off debt but generally too new to the group to feel comfortable expressing strong opinions.

There were also singles in each career stage that would not be averse to new ideas as long as those ideas did not come at their expense.

Recruit powerful allies

I began by reaching out to a charismatic, mid-career superstar in our group married to another physician with a toddler.

She had built considerable good will by being the first to offer help when someone asked to swap out of a shift; was beloved by our staff for her unflappable good mood; and was well respected as a brilliant clinician.

If I could enlist her as an ally, I felt it would lend credibility to the cause – who was going to deny this rock star’s reasonable request to accommodate her family life?

We met for coffee, and I confirmed that she was equally unhappy with the current situation. She also confided that she was expecting!

We decided that a combination of mid-career docs (who stood to gain time) and young guns (who stood to titrate their earning potential to achieve balance) might be sufficient to overcome expected resistance from the traditionalists. We bounced ideas back and forth, refined them, and came up with a plan.

Frame the issue properly

If I had approached the problem as one doc’s unhappiness with burnout, it might not have gathered sufficient support.

For some less sympathetic colleagues, burnout means you need to step aside to make room for someone else who is willing to do the job as it exists.

Instead, I framed the issue as one of fairness to those with family commitments. I chose an expecting mother everyone loved to help me champion the change.

Our group is not a sausage party, and we are fortunate to have a large number of reproductive age female physicians choose to work with us.

Like my wife, many female physicians felt the dual tugs of a large mental load (being expected to run a household) and a large clinical load. Our message resonated with them.

Like me, there were sufficient male physicians married to working spouses who wanted to help them shoulder the mental load. Our message resonated with them as well.

Instead of one male physician’s crusade against personal burnout, we hoisted a banner to make emergency medicine as practiced at our hospital compatible with a higher level of engagement in family life.

It becomes difficult to argue to preserve a sclerotic scheduling system that prevents a parent from participating more fully in family life.

On the flip side, it becomes a unique recruitment tool to offer flexibility that attracts top candidates who value flexibility in scheduling. The program promised to add to the many enticements that make our work environment desirable.

We attract and retain phenomenal physicians because we are a family friendly workplace.

One size does not fit everyone

Since joining a decade ago, our group had operated on the assumption that an equal shift load translated to equality of impact.

This benefited from simplicity: divide the number of available shifts to fill by the number of doctors, and everyone worked their share. It was time we stopped pretending that one size fit all of us in medicine.

We proposed an alternative concept, which allowed individual shift load to vary by individual need: each equity member of the group would name a target number of shifts to work each month, and must be willing to settle for their target +/-2 to account for seasonable volume fluctuations.

Ensuring financial security

This addressed financial security: each person would select a minimum range that would enable her to meet financial goals or obligations.

Ensuring balance

This allowed tailoring of a career to individual needs that varied by physician: a single young gun might work 15 shifts a month, while a hands-on parent could reduce his shift load to 10 and make it to the soccer games and piano recitals.

We decided as a group on a range of shifts that would qualify for the benefits of full equity status (full profit sharing), and a lower range of shifts that would create a new, partial equity status (half profit sharing).

Ensuring fairness

One of the features that was added to make the proposal palatable to the traditionalists was a clause that all members, whether partial or full equity, would take equal bites of the “crap pie” by assuming a proportional number of nights, weekends and holidays.

Those who worked partial equity were valuable to others because the shifts they took included the less desirable shifts (nights, weekends and holidays). Ex: I work six shifts, but half are lousy, I’m at 50% lousy shifts.

Those who worked full equity or had a greater target number added a larger proportion of desirable shifts (weekday days). You work twelve shifts, but a third are lousy, you’re at 33% lousy shifts.

Hence, the partial equity track members were valuable to those who might otherwise express skepticism toward their non-traditional workload.

An unintended consequence of this clause was that it did not address an ability to reduce night shifts. This was an oversight, and I am currently gathering support for a night shift differential to address this issue.

Capping the potential for unanticipated pain

One of my biggest concerns was that I wanted a ceiling to my pain. The old way of doing business had meant that all shifts vacated by folks on a leave of absence were divided equally among the members.

Adding 2-3 shifts to my clinical load was enough to make the difference between feeling an essential part of my household vs. my being a vaguely familiar, “Don’t we know you from somewhere?” phantom presence at the dinner table.

The new plan addressed this as well: during periods of prolonged leave of absence, partial equity members would be allotted one extra shift for every two extra shifts allotted to equity members.

This made the decision easy for me: I chose the partial equity track. While this meant I sacrificed significant income, the benefits were priceless. Interestingly, I was the sole member to avail himself of the partial equity track in that first year.

A significant number of people, mostly mid-career docs, opted to reduce their clinical load to the minimum needed to qualify for the full equity track, and their levels of happiness blossomed unexpectedly. Several people who were skeptical of the plan became its most enthusiastic cheerleaders.

Every year, members are surveyed for their desired number of shifts, early enough so that we can hire to address any shortfalls. Under new leadership our group has not suffered the severe under-staffing we did during those brutal two years.

If you are thinking about trying to cut back in the next few years (are your ears burning, Physician Philosopher?), consider what parts of this playbook might work for your journey.

Comments 12

  1. Good on ya man! If you can get the group to stratify their income based on lifestyle needs that’s a major game changer. It’s you can have anything but you can’t have everything. Be vigilant to policy drift because physicians are nothing if not capitalistic. Capitalistic wrt to time and money. In our group we went from FFSPP solo practitioners to a one for all all for one group practice and the mores changed from pure eat what you kill, to split the pie equally therefore you maximize profit by minimizing work aka communism. 40% of the income came from crap pie and it needed to be done. We had one Russian guy who specialized in going home at noon. I guess he had some really important episodes of Gilligan to watch. Unless you have a close understanding of systemic drift in the actual practice vs presumed rules of practice, and take some action early resentment will build, so you need some iterative mechanism to monitor progress in the plan. You don’t need to be hyper anal, just anal enough. I used a 90% rule where you had to be satisfied with getting 90% of what you want. 10% slop multiplied by 7 players left a lot of flexibility in tailoring a successful outcome. If you make it 95%, not enough slop. If you get a kingdom builder get rid of him. He will destroy the system. There is no reason to sacrifice the group for one ego.

    I’m proud of you! This is the subject of your book and the basis of your consulting business. Being a Unicorn has it’s downside, you become a target for Blackstone to come in and take over the contract.

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      Author

      Gasem,

      Thank you for the supportive words. “Lifestyle stratification” has a catchy ring to it.

      1) Definitely have moments, usually when we hear about another independent group biting the dust, where we can feel ourselves fall under the spotting scope of a predatory corporate interest. This is where decades-long relationships bear fruit over time to stave off the wolves at the door during this cold winter in medicine.

      2) I’d love to read more about your adverse experience with the kingdom builder, if I didn’t miss this post on your site (just catching up on my reading from the past week).

      3) Your 90/10 rule sounds about right. 90% still gets you an “A,” and in these Lake Woebegone days where all the children are above average, every child will be happy with an “A” average of getting what they want.

      4) The divergent work ethic of a salaried employee vs a business owner/investor are precisely as you describe. My father’s family escaped from Castro’s Cuba for similar reasons.

      5) Never thought of this as a business opportunity, but you got my gears turning…

      Thanks for always angling the situation just enough to alter my perspective for the better,

      CD

      1. Tweaking your brain is my feature!

        Kingdom builders are people that treat the group as an object to be used for their personal benefit, not an organization of people who have needs and aspirations of their own. They are typically skilled at manipulation and maneuvering through guilt and FUD (fear uncertainty and doubt). It’s a kind of game theory to gain advantage. The problem is medicine is too hard a job for the other players to have games superimposed. If you loose group cohesiveness factions form and things blow up. When I was doing locums the reason I did it was to learn how groups work and where I might fit best, and locums usually comes to keep forward momentum happening in the after math of blow ups. If you hire locums listen to their experiences or listen to new players experiences of their old practices once they feel comfortable enough to share the truth. People usually don’t leave a job they like.

  2. Wow CD. What an awesome idea you envisioned from the get go and what a wise decision not to approach it from a single front but by rather gain allies and attack from multiple fronts.

    Your group is incredibly lucky to have you. I bet just by implementing this you have reduced burnout dramatically, decrease attrition rate/higher retention rate, and as you said have a carrot to dangle when hiring talent who would likely choose a setup like this over a competitors (even if there is a lower pay).

    I chose my current group (been there 12 yrs) precisely on valuing family time over money and it was the best decision I could have made. I had I believe 4 other offers, all offering more money, but it was the no nights, no call attraction of this practice that sealed the deal.

    Wonderful post and wonderful result.

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      Author

      Xrayvsn,

      The long game will hopefully reduce burnout and attrition. The short game is simply trying to build a fragile consensus that recognizes this is a problem that warrants a solution.

      I’d love to say my suggestions are welcomed, but in truth they can be perceived as disrupting a system that already works for many colleagues. I can see their point. These are reasonable people who care deeply that I find myself disagreeing with.

      I’d love to see our group enhance an already strong reputation as a desirable place to build a career into a place that supports balance, with a trajectory that allows for (as Gasem so eloquently put it) “lifestyle stratification.” You want to earn more as a young gun who is hungry – you go for it. You want to ease out of the hardships of the job, you can pay dearly for that privilege while making it a win for your colleague.

      I’m grateful to work with thoughtful folks that are willing to listen. I’ll keep acting as a gadfly, asking how we as a group intend to address important questions, and let’s hope there’s no hemlock in my future.

      Appreciate your encouragement,

      CD

  3. Hi Crispy Doc!

    Wow! This is one of your most impressive posts yet. Helping a group reshape how it practices is a very big deal. Your description of barriers, strategy, and change management was excellent. We may be in different countries, but we have walked very similar paths on this one I think.

    Our group made similar changes. It took a decade to finally arrive where we are now and we would never go back. One issue that has now crept up is that it is a bit difficult for those looking at our group from the outside or just joining without having seen the journey to understand how it is “fair”. We have a mish-mosh of different people doing different clinical and non-clinical roles. This has allowed everyone to find their groove and our productivity is off the charts. The careers of some of our aging, but super productive colleagues, has also been extended. So, the “traditional crowd” are now some of the strongest converts.

    I have found myself (I am Chief) having discussions of “equal” vs. “equitable” to newcomers or those outside our group. Equal is very easy for people to understand. Everyone does the same. Simple. It is also harder for those just starting out after a decade of focusing on their career training to understand that “life” intercedes more as you age, have long-term relationships, kids maybe entering the picture, or parents aging. Equitable accounts for these things plus other often undervalued non-clinical roles. However, it also requires more thought and empathy to understand. It is not cookie cutter. We have started having annual open discussions where we attach FTE values to the various non-clinical roles people do. That helps make it transparent and hopefully fosters empathy for what each other does. Another key for us was to make sure that equal work has equal pay.

    That took some reworking to redistribute from the “desirable” services to “less desirable” ones. It also took a redistribution of pay from the “day people” to give nights a premium. That was the toughest one because previously there was not requirement to fill in the night gaps and the days paid much better. The solution was to say “either we pay nights a premium from days or everyone does equal nights”. That resolved it quickly and people self-selected.

    Looking forward to the unfolding of your group’s adventure. Hopefully, it will inspire others. I am inspired by it.
    -LD

  4. Dude, congrats and thanks for sharing your secret recipe!

    How clever of you to recruit a brilliant, beloved, expectant MD who could brainstorm with you and get the majority on board. You and Loonie Doc are an inspiration.

    Enjoy your newfound life and happier wife. 😉

  5. I thought about this more and here is how to systematically think about this

    There was a 19th century mathematician physicist and chemist named Josiah Willard Gibbs. He formalized physical chemistry into a precise discipline aka brilliant. He gave us the Gibbs free energy equation among others. Gibbs free energy is a state equation. It means a system goes from one state to another state independent of process. You can fly to Nevada from LA or you can drive, by either process way you changed your state to the same state. Gibbs free energy is an expression of heat and disorder You recall dG=dH-TdS where dG is change in free energy, dH is change in internal heat and TdS is change in entropy time temp in K. All systems contain heat and order. A system spontaneously will give up some heat and order if the above equation turn negative. Order in this case are the fossilized “rules” and heat is burnout and dissatisfaction. Burnout wants to leave, the ordering rules are kept in place by peeps wanting to maximize income at all cost and that imposed order is what makes wives unhappy. If you can increase S aka disorder eventually the energy hump is breached heat is released (exothermic) a new less ordered, order, is achieved and the system has a new state of lower heat and lower order. Lower order means less constraints on life style it also means less income since H is the income equivalent. That’s the story. Every physician has been exposed to J Willard Gibbs and the precision of his thought and state analysis and this might be a way to explain in a kind of mathematical way the benefit and cost of your system and benefit of your system. The reactant side has it’s order and heat. The product side has less heat and greater freedom. You can choose what to be. If you’re reactant your life is constrained and heat filled but you make a lot of money. If you’re product, your life is less crispy and more free but you make less money. Nobody is getting gypped people are just acquiring their desired level of heat and freedom. The system is about states not process, so focus on the states not the process. If you focus on process you get lost in meaningless details. Now go write your book.

    How could you not love someone with the handle of Josiah?

  6. I’m a few years behind you on the path to FI, but I would love to implement something this like in my unicorn EM group.

    I like the idea of the part timers working less desirable shifts to keep things fair. The night shift differential would be a huge win.

    Please please please publish a “how to get out of nights” once you crack the code.

    1. Post
      Author

      You are younger, but so much more on top of it than I was at your stage. I’ll keep you posted on the nights – suspect it’s less likely to be a one-size-fits-all solution than a fragile consensus.

      WCI would say that the night solution should be a market solution, and he’d be completely correct – there will be a sweet spot where the night differential makes demand slightly exceed supply. Your role is to become financially secure enough to pay your friends dearly for the privilege of having them work those nights so everyone wins.

      I promise to share anything I learn. By the way, your posts over the past month have been on fire – I’m loving what you have to say as much as how you say it.

      Fondly,

      CD

  7. Your description of your group and your process mirrors my own, in many ways, and likely that of many similar medium size contracted physician practices.

    Historically, we have strived to have all full time partners, who shared the workload fairly (if not exactly equally), and equally shared the money at the end of the year. This was the perfect model for the 70’s and 80’s, when my group was comprised of all men with SAHM wives. Even when I joined the group in the mid-90’s, I was the only male rad in the group with a wife with a professional career. Interestingly, when I look around my partnership today, I am currently the only male partner with a wife who has a full time professional job. (There are two with wives who are part time primary care docs.) One of the three women has a rad for a husband.

    Over time, the fair division of work-equal compensation model has fallen by the wayside, but there is a reluctance to abandon it, for a number of reasons. One of these is that in order to create a system, in our own world, where compensation can be tied to a specific level of participation, when you start eliminating people from the least desirable shifts (for us it’s a weekend shift of 24 hours out of 36), you have to place a value on it. This should be easy to do, you say.

    Well, it is not. A random weekend from mid-February to mid-March, in our world, is valued much lower than, say, Memorial Day weekend, Labor Day weekend, or Thanksgiving weekend. Then, there are idiosyncratic weekends, like Super Bowl weekend, highly valued by me but ignored by many. Easter weekend is meaningless to me but obviously valued by others. Heaven forbid that Christmas is on a weekend or on a Monday (even Tuesday, as in this year). One of our partners who took it upon himself the create a valuation system for all of the shifts and responsibilities was literally driven to a nervous breakdown attempting to codify it all.

    Mental anguish aside, shift-based hospital-contracted groups are going to need to adapt to accommodate a workforce in which individuals who have different priorities that will fluctuate over time. I can talk to the same partner, who will tell me that s/he “needs more time off, screw the money” and one week later will tell me that s/he “needs to make more money, screw the vacation”. The fact that we do not even know ourselves what our individual goals are, on a consistent basis, makes it very frustrating to effect sweeping policy change within the group.

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      Author

      Your comment is fascinating, Vagabond. You are one of the privileged few (I’d put Loonie Doc, Wealthy Doc and Gasem in this category) who has been in the decision-making position as Chief or Director of a group responsible for making decisions that affect group policy as a whole.

      You have experienced both the difficulties of administering a policy where partners do not exhibit constant workload desires over time as well as the feeling of burnout that left you seeking a more flexible policy.

      My pitch to you: How about a guest post describing how to sell your policy to enable cutting back a medical director of chief, from the perspective of a former group director? What were your third rail requests that might have instantly voided any proposed policy to cut back? What would have made it palatable and made your job easier?

      Consider it. I might even ask Gasem, Wealthy Doc and Loonie if they’d be willing to provide posts from their perspectives, since while I imagine certain themes might emerge, there’s likely some variability in the answers.

      Train of thought leaving the station excitedly,

      CD

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