Large group medical practices: Understanding the human dynamics

August 1, 2009

The larger the practice, the greater the potential for personality clashes. People-savvy leaders offer advice on how to avoid conflicts.

On the surface, people problems don't have the alarm-bell urgency of financial challenges that directly impact a practice's bottom line. Yet failing to define and nurture a cohesive culture can lead to poor hiring choices, high turnover, and misguided or ineffective decision-making, any one of which can put a practice 6 feet under.

The human side of group survival

Large medical groups, in particular, need to wrestle with culture, communications, and decision-making, among other aspects of human dynamics, says Fabrizio. Instead, "they have the attitude that they can handle the hard issues-the spreadsheets and the data-but ignore the cultural component. They tend to assume that, 'we deal with life-and-death issues so this stuff is no big deal; everybody will get over whatever is bothering them.'

"But people don't get over it," he says. "What happens is they have one foot in the practice and the other out the door looking for a job elsewhere."

Indeed, a 2006 survey conducted by the American Medical Group Association and Cejka Search, a physician and health-care executive search firm, found poor cultural fit to be the leading cause of physician turnover. More than half (51%) of groups surveyed cited poor cultural fit as the cause of turnover within their organizations, well above compensation (32%) and schedule/call responsibilities (17%).

Cultural challenges are much more pressing today than they were 20 years ago because the nature of medical practices and the pressures they face are very different, experts say. A generation ago, most doctors were white males working alone or in small practices. Today's workforce is much more diverse, and colleagues have different priorities. For example, younger physicians may want more work-life balance, and mothers of young children may be interested in working part-time or job sharing. What's more, young physicians may be less interested in buying into a practice than simply earning a comfortable salary, a preference older doctors may regard as a lack of commitment.

The economic issues that today's physicians face have changed as well. Increased financial and reporting pressures allow practices little room for mistakes. "I've had a number of clients tell me that in 1985 they could afford to make a lot of stupid decisions," says Bruce Johnson, a partner with Faegre & Benson in Denver and a consultant with the MGMA. "Now you can't afford to make a wrong decision about purchasing an MRI or offering ancillary services."

Finally, the environment in which physicians are practicing has changed. Financial pressures have forced many doctors to join larger groups. Decision-making is no longer a matter of end-of-the-day conversations in the hallway, and communication requires much more than a quick lunchtime chat. Equally important, physicians may have been drawn into these practices not by choice but as a means of surviving. As a result, many arrive with resentments and attitude problems, says Lynn Helmer, an internist who went back to school to earn an MBA.

"I went to learn about finance and accounting," says Helmer, who is president of DRD Consulting in Haddon Heights, NJ. "I didn't think anybody had anything to teach me about people management and strategy."

Many of the people problems that plague medical practices are not unique to them, experts point out. Other professional services, including law and accounting practices, are facing similar issues. What's more, cultural issues often creep up slowly as firms grow. By the time the group recognizes a problem, it has become entrenched.

What sets physicians apart, however, is their training. Not only are they not trained to deal with issues regarding personnel and strategy, they're trained in a hierarchical manner, says Helmer. "They've been schooled in an approach that says, 'I'm the lion, hear me roar,' but today business is really moving more to a team model."

Every practice has a personality

"Not taking the time to understand the culture up front is a recipe for disaster," says Helmer. "If you're bringing people into the practice to be one big happy family, then you really have to take some time to understand what it takes to make a big happy family."

Because cultural conflicts take time to develop, they take time and concerted effort to fix. The first step, experts agree, is stepping back and defining the organization and what it represents.

A mission, vision, or purpose statement can help an organization define its aspirations. A values statement can help identify the organization's priorities. Those values need to support the long-term mission, Helmer emphasizes. Such guiding principles are essential to effective decision-making and intelligent recruiting.

"I always thought purpose statements were silly, but later realized how important it is for groups to define their culture," says internist Mary Ann Bauman, medical director of Integris Physician Services, an 80-physician practice in the Oklahoma City metro area. "Our culture is to work hard, provide excellent patient care, and make money. I've interviewed physicians who wanted to share a job, and their goal was to wind down, which was different from those of us in the group. That wasn't going to work. We expect doctors to actively go out and build a practice."

Like personal ads, organizations have a better chance of attracting the right suitor if they have defined their vision and values. For example, a group that values inclusiveness may have a nurse leading a quality committee or an office manager on the strategic planning committee. That type of decision helps a group define itself in the eyes of staff members and would-be recruits.

"When they merge, many groups spend a lot of time with their lawyers figuring out how the old pension plan will work after the merger," says Helmer. "That's important, but they don't spend enough time with this other stuff, which in the long run is going to be more important."