Higher satisfaction, pay demand new deal between groups, MDs

Physician Compensation Report, April, 2003

PCR interviewed Jack Silversin, D.M.D., D.P.H., president of Amicus, a consulting firm in Cambridge, Mass., about methods of maintaining and improving physician satisfaction in today's difficult economic environment.

How are physician satisfaction and effective group operations related? They depend on one another, and they both depend on physicians understanding how to operate in and contribute to the group in today's environment. Low satisfaction often is a reflection of and contributor to poor performance, and high satisfaction is a reflection of and contributor to good performance. Satisfaction and performance both depend on physicians stepping back and developing the attitudes and work habits needed in the current environment.

Is physician compensation a part of this equation? Yes, it's a key variable. Compensation is important to most physicians, just as it is important to most people. Doctors frequently ask themselves, "Am I getting my fair share?" They mean that partly concerning the amount of pay--"Is the amount of my pay fair in light of my effort?"--and partly concerning the group's internal pay system--"Is our group's way of dividing pay fair to me?"

It's essential, though, that we not put the cart before the horse. Compensation is part of the satisfaction package. Other significant issues enhancing or reducing satisfaction include involvement in decisions, communications, and feeling respected and valued.

Can the focus on compensation hurt satisfaction? I know doctors who make a lot of money and aren't happy. Groups with an intense focus on making money sometimes lose focus on other things that could contribute to physicians feeling valued. I work with a lot of groups around the country, and I have very little sense that most physicians believe or are told that they're valued resources apart from what they contribute to the bottom line. Part of the problem is with physician and practice managers who put such a heavy emphasis on production. To focus only on money as a source of satisfaction is a losing game.

How do you see this playing out over the next 10 years? Most groups I know are struggling to achieve their good business performance. Most doctors either are working harder for less money, or their workload is rising much faster than their pay. Despite the recent reprieve for this year on Medicare reimbursement, I foresee heavy pressure on groups' and doctors' incomes continuing for many years to come. Groups--to survive--will need to develop a sense of doctors and staff being valued apart from the money they bring in, and to learn other forms of appreciation in addition to compensation.

What are the attitudes and behaviors that many physicians need to learn for their groups to survive and prosper? Let's step back a moment and look at what I call the compact between physicians and their groups. Most physicians joined their groups with this understanding: "I see patients and function as a good doctor, and in return the group provides me with three things--autonomy, protection, and entitlement." Autonomy meant the doctor was left alone, not questioned either clinically or business-wise about his or her operation. Protection meant the group was a buffer between the physician and the marketplace, so that he or she did not have to pay attention to business details or staff concerns. Entitlement meant anything from the best parking spaces to referrals to raises, whether or not the group could afford them. This traditional compact worked well in most groups for many years.

Is any one of these three most on the endangered species list? Yes, autonomy as it was understood is significantly challenged. Complete clinical autonomy without accountability isn't going to come back, nor should it. There are outside organizations demanding, for instance, that each doctor's clinical treatment of patients with certain chronic diseases be more uniformly managed, and that each doctor's schedule be revised to maximize patient access.

How do doctors feel about losing the old deal? With new forms of accountability, there's tremendous pressure on doctors to change. What I hear the most is, "I didn't come here for that." One of the biggest stress and dissatisfaction factors is simply the clash between the old compact and the constant demand for change.

How do physicians learn to deal with so much change to what they thought were the basic terms of their working life? I have found that it really helps most groups and doctors if they talk about and eventually even write down how those basic terms have changed and what the new terms are. For instance, if the organization's agenda includes improving quality, access, patient satisfaction--and production--all in measurable ways, then you probably need to renegotiate a new deal.

This is your "compact" concept? Yes. There's still a "give" and a "get," but they're quite different than the old deal. There's still professional respect, but not unfettered autonomy. Instead of passive protection and entitlement, the expectation is that doctors are actively addressing new clinical, business and operational challenges. You can learn more about ways to establish a new compact at my Web site, www.consultamicus.com.