Leading Beyond the Bottom Line: Part 2 (updated)

Last month I introduced the conceptual model of the Pareto Optimum espoused in Leading Beyond the Bottom Line. I explored how that model might provide a philosophical basis for recasting our relationship with our hospitals. As a reminder, LBBL suggests that as physicians act evermore like managers, focusing solely on the bottom line, they’ve foregone the physician-manager’s unique opportunity in healthcare. The physician-executive authors of the LBBL approach assert that rather than only assure an operating margin, the physician-manager can assist the health care entity in reaching the Pareto Optimum among: Patient Care, Financial Health, Employee Well-being and Community Commitment.

This month I’d like to take up the far thornier—and closer to home—challenge of discussing how emergency physician leaders who embrace the LBBL approach could strengthen their practice itself and, perhaps, help us in emergency medicine emerge from the dichotomizing rhetoric of the past half-decade in our specialty’s ranks.

Before explaining this difficult thesis, I must digress and explain some of the concepts I will use below, particularly that of the “zero-sum game.” Theorists describe a zero-sum game as any circumstance in which the balance gained and lost among any number of “game players” (read this as negotiators, warriors or doctors and hospitals) adds up to zero. Wins and losses add to zero for the group as whole. We’re also familiar with the metaphor of “growing the pie” consequent to which all that “play” gain, even though holding only a constant portion of a growing endeavor.

Nonetheless, moving the LBBL concept from the macro level down to our own practice, whether salaried, fee-for-service or an amalgam of both entails a parallel description of the apparently “competing goods or objectives” that we might strive to balance within our practice, even as LBBL offers a model for use by the hospital and the communitarian movement[1] proposes a particular model of balance for our greater society.

As always, our patients are the reason we strive for the Pareto Optimum in our practice. Our personal and economic well being parallels the need for the hospital’s financial security and engagement with our hospital both at the general medical staff level and with administrative leadership parallels the hospital’s engagement with its broader community. Lastly, engagement with both physician colleagues in our practice and those who work along-side us in our emergency departments identifies the fourth component of our practice environment’s Pareto Optimum.

Few of us have consciously addressed the competing interests in our personal and professional lives at a conceptual level. Most of us make tradeoffs between personal and professional commitments that compete for our time and attention, but few of us do so within an explicit framework. Self-help books abound and it’s not my intention to fit one into this month’s column. Rather, just as I asserted in July 2000 when I wrote about the pyramid of medical staff development, leadership requires making that which is implicit, explicit for your colleagues. Thus, the open, but structured discussion of how well—or poorly—you as a group are succeeding in meeting competing objectives broadly grouped in the four categories I’ve described above, can begin building a new, strengthened group purpose.

So, how can we actually strengthen our practice team and reduce the din of the argument among us while re-affirming our leadership within medicine as publicly concerned caregivers and safety net providers? I recommend open, structured discussion as the first step.

How to begin? Just as last month I suggested you share the LBBL article with your administration, so too you should share it with your physician colleagues. At a subsequent staff meeting raise one issue that is current within your group. Perhaps it is turnover or income or conflict with members of another hospital department—or perhaps it is restiveness over the administrative charge paid from practitioner earnings to your management group. Whatever it may be, raise it and make it explicit to all and proceed to characterize it within one or more of the four categories.

As an example, the resentment of some group members over what appears as apparently confiscatory administrative charges might be mitigated by the complete neglect by those same staff members of participation on medical staff or hospital committees or project task forces. If all of that work falls on the group leaders, should they work the same clinical hours in order to maintain income? Here we see that within the group the balance between individual economic well being and “community participation” may be out of kilter. Conversely, arbitrary disciplinary actions taken by the group manager against a staff member ostensibly engendered by an effort “to save the contract” suggest that collegial support and economic performance are similarly unbalanced.

I’m not denying that throughout the history of emergency medicine, charlatans and thieves have harmed patients, colleagues, hospitals and communities. Undoubtedly malefactors among emergency physicians, both practitioners and managers, continue thriving parasitically upon some emergency physicians today. Yet, I’m equally certain that the cause of resentments and conflict in the average group practice is more often the failure to explicitly address the apparent conflict and competition among the four components of the LBBL model.

Few practice leaders have management training and believing themselves smart—probably correctly—and while wanting “to do the right thing,” most have little knowledge and still less experience in balancing competing human interests beyond clinical work during a busy ED shift. Consequently, just as most humans avoid confronting difficult tasks, it’s natural for a practice leader to avoid confronting colleagues with the process of striving for balance. Particularly so since once undertaken, striving for the Pareto Optimum becomes a continuous effort, much as physiological systems depend upon continuous homeostasis for balance, so too will the gathering of colleagues known as “the practice” require continuous effort to maintain the Pareto Optimum.

Explicitly seeking your group’s Pareto Optimum among patient care, personal financial security, engagement in our hospital and medical staff community and engagement with colleagues and co-workers presents the opportunity of including not only those who depend upon us in our personal lives but also those dependent upon our medical safety net services even as we enhance the quality of our professional lives in the process of reaching our own Pareto Optimum.


[1] The communitarian movement, attempts to address a just society’s dual need for both social order and individual autonomy. Their concepts also inform my view; although, I assure you I’ve not embraced that particular movement and neither do I have the space, the inclination or my editor’s permission to discuss political theory in this column.