Bastiat, a Teenage Magician, and Medical Group Decision Making

A magic show is about misdirection: that which is seen and that which isn’t seen. Just like the title of the essay by Frédéric Bastiat, the early 19th Century French political economist, but in a slightly different direction.

Bastiat’s point was that governments legislate to correct a problem (and then bask in the glory of having taken action) but never truly consider what problems they create when they enact the legislation to correct the problem. In other words, they act based on what is seen (the initial “problem” and the easily seen “solution”) but do not pause to consider the potential damage that their action will later cause.

For example, in the United States we had the Great Society movement — Lyndon B. Johnson — supposedly to help the poor. One of the prime programs was public housing, which, in actuality, deserves significant blame for having created an almost permanent underclass which is dependent upon public housing and other government programs.

The Great Society programs and the slice of help that they provided to then current beneficiaries was “that which is seen.” Unfortunately, the negative impacts, the “that which isn’t seen,” were never taken into account and never even considered.

It part, we can blame this on the short lifespan of term of office. “I’ll be out of office and retired in the Bahamas before the shit hits the fan.” In part we can blame this on the immunity from liability for negligence that we’ve given politicians and bureaucrats: I’ve heard, but can’t find any proof, that the Romans made bridge builders live under their bridges for a period of time, the ultimate test of quality planning and construction. We don’t impose any risk at all on politicians who impose harebrained schemes on us.

But, in large part, the problem is one of thinking, and it pervades industry and child rearing (“Okay, little Johnny, you can have another ice cream cone, just be in bed by 7:30 . . .”) and decision making of all sorts, including that within medical groups.

There are many methods by which a medical group can make decisions. Some are clearly ill advised and others far more likely to generate good results, or, at a minimum, results that can quickly be corrected.

But any decision making method must be governed by a decision making process: what is considered in making the decision?

To drive the maximum chance of success, both in terms of advancement and in terms of managing against risk, the process must incorporate not only a view to what will be achieved by the decision, but also a view as to what deleterious impact the decision itself might bring, perhaps not immediately, but bring just the same. Think plus and minus. Think positive and negative. Think that which is seen and that which isn’t seen.

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

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Governance | Group Culture

Why Your Group Has to Get Out of Its Own Way: Governance

Overly democratic or consensus style systems of medical group governance make it impossible for the group to adopt a strategic, as opposed to a tactical, outlook.

For example, consider a consensus style group that is unable to come to agreement on how to respond to an important referral source’s request that they expand their office hours. From a purely tactical standpoint, the group considers the cost of the extra hours of operation and, although unspoken, of the convenience factor as run through each doctor’s personal filter.

But the strategic analysis is very different: If we value their referrals, how do continue to obtain them?

As to the question of who should be making that decision, true democracy doesn’t work in business any more than it works in running a city, state or nation. As I advise clients, I’m a strong proponent of the “strong leader” form of governance. Whether that leader is grandfathered in or elected every year or two is an issue that turns on the culture of the specific group. If elections are the culture, that’s where democracy comes into play: representative democracy.

Leaders must be empowered to lead. Not all of their decisions will be good ones, so they must be free to fail as well as to succeed. Requiring a group vote or establishing a board consisting of all of the shareholders guts leadership and replaces it with its poor relation, consensus, which by nature suffers from the defects of peer pressure and compromise.

Lead, follow or get out of the way. Or, as the English author G.K. Chesterton poetically put it, “I’ve searched all the parks in all the cities and found no statues of committees.”

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss


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The Fortune Teller

From down the street I could see the fortune teller’s shop.

Did she know that I was coming?

Go ahead, laugh. But if you’re a member of a 15 or more person medical group, do you have any clue, any clue at all, about your group’s future?

I’m a fortune teller of sorts. I can tell you that most groups that I’ve come into contact with are as clueless as you are as to the future. Chiefly because they’ve never sat down to consider it. And, even if they’ve done that, they didn’t take action to create their own path forward.

Instead they labor away at providing medical care. They may be very, very good at that laboring. But it doesn’t help them in preparing for the future.

The skill set that helped them get from the start of their careers to the present, improving their skills and building their practice, is a hindrance to getting beyond the present circumstances.

Digging in, being collegial, even protecting the group’s turf at Community Memorial St. Mark’s hospital or the referral relationship with the Jones Internal Medicine Group will, at best — and even then it’s a leap of faith — protect the group’s current situation. In other words, it’s a purely defensive move.

But the times (actually, any times) requires that you play offense.

Sure, you may develop a plan, implement it and fail. But failing forward faster is better than doing nothing and becoming a bit player in someone else’s future.

You don’t have to be a fortune teller to see that.

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

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Hospital Administrators Assume That Your Group Is Out of Control

If you are a hospital-based physician, you can be certain that there are one or more so-called national groups targeting your facility. That is, they want to put you out of business.

Probably better said, first they want to take some or all of your current physician staff, and maybe some of your non-physician staff, and then they want to put you out of business.

If you are an office-based physician, this isn’t the time to gloat. That’s because in many office-based specialties, this same trend is beginning to emerge. After all, if hospitals have their way, sooner or later all physicians will be hospital-based.

I’d like to address one of the several grounds on which national groups compete: governance.

National physician groups and the practice management or contract management companies, by whatever name or acronym they are known, masquerading as true physician groups or purporting to be able to provide staffing, generally portray local groups as being disorganized, out of control, and deficient.

In other words, they simply assume you are damaged. Unfortunately, most hospital administrators make the same assumption.

As a result, the national group’s pitch often resonates.

This should both scare and empower you:

Scare you because if you do nothing to improve the governance within your group, you are leaving an open door through which you can expect a competitor will enter.

And, empower you because knowing that your competitors are looking for an open door, and knowing that administrators most likely see your group as lacking in governance, whether it’s true or not makes no difference, enables you to focus on this issue as early as possible, which is right now.

Specifically, we’re looking for two important elements:

The first is adopting a streamlined group management structure. A system that can make decisions and take action quickly.

The second is creating a structure that can deal effectively in managing the behavior of group physicians.

Sure, as in planting a tree, the best time to address governance was many years ago. But the second best time is today.

Comment or contact me if you’d like to discuss this post.

Mark F. Weiss

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