Ask just about any job-seeking emergency physician what he is looking for in a job and the word “partnership” is bound to surface. The problem is that this word is bandied about as much as the word “democratic” these days, even in situations where neither really exists. Many of those who use it don't even know what it means.
The popular pursuit of partnership started in earnest back in the late 1980s and early 1990s with the backlash against national contract groups and the concept that emergency physicians were being badly treated by many employers. The belief was that hospitals and contract groups, large and small, were treating EPs as shift labor that were not being properly compensated for their time, qualifications, and efforts. Physicians began demanding an open books policy, a voice in running the department, and a financial piece of the pie.
This debate even saw the creation of a second specialty organization, the American Association of Emergency Medicine, which advocates for “the ideal practice situation in emergency medicine [that] affords each physician an equitable ownership stake in the practice. Such ownership entails substantive responsibility to the practice beyond clinical services.”
This is a wonderful goal to be sure but not easily achieved. More than 50 percent of the emergency physicians practicing today — who are hospital employees, employees of large or national contract groups (even those primarily physician owned and run), and academic faculty — have no chance at this ideal. There has been much discussion about a cruelly dangled banana few are capable of reaching, and raising the expectations of emergency physicians, particularly graduating residents, to unachievable heights. On the other hand, if ideals are never set down, how can one be expected to reach for them?
Though groups of emergency physicians staffing either single or multiple facility EDs as equal partners have been in existence since before the official inception of the specialty, it is only in the past 10 years that the pursuit of partnership has taken such a primary role in the average job search. If emergency physician job seekers are going to focus on partnership, it is essential for them to understand exactly what partnership means in each job opportunity that claims to provide it. They must be clear about when and how this partnership is earned.
One of the things that has made the concept of partnership or ownership even more complex is the recent popularity of incentive compensation. Many uninformed physicians mistakenly consider this extra income a form of partnership. Incentive compensation such as bonus pools and hourly productivity bonuses are just that, a means of compensating a physician for his performance based on productivity, patient satisfaction, and contribution to the department and hospital. But it is not partnership. Possibly an even more important factor is that physicians, particularly graduating residents, are not spending the time and effort to analyze the practice structure that best fits their individual professional and personal needs and desires. Not everyone is cut out to be a business owner with all the time and energy that role requires. It's essential that physicians evaluate their goals as they apply to short- and long-term practice commitments, and understand how each opportunity they consider fits them.
There are quite a few partnership modules in existence within the groups staffing emergency departments today, and the principal three are equal equity ownership, limited liability partnership, and non-equity partnership.
Another element integral to the subject is that partnership and ownership potential is rarely, if ever, guaranteed, either verbally or in an employment contract. So why does the average graduating resident seem to believe that partnership is an immediate inalienable right not unlike free speech? As a professional recruiter and residency program lecturer, I can attest to the fact that the popularity of partnership as a job market buzzword has led to an inflated sense of entitlement among graduating residents. It's not their fault. Many grads are being led down the primrose path by a new kind of specialty folklore that tells of huge annual incomes and management roles from day one. This can result in inevitable disappointment when the promised riches don't materialize rapidly enough, and the physician starts looking for greener pastures. This is one reason for the high percentage of graduates leaving their first job within two years.
Any experienced emergency medicine group partner or owner, no matter the form that position takes, would agree that partnership must be earned, not simply conveyed on the first day of work. Earning partnership or ownership, particularly in an equity situation, not only takes years, but often a financial contribution in the form of a buy-in as well. And because less than 50 percent of the jobs available this year will be with groups providing eventual partnership or ownership in any form, graduating residents with those goals should focus on asking prospective employers these questions:
- ▪ What are the criteria for earning partnership or equity ownership, including the specific formula?
- ▪ At what point does eligibility become available, and what specifically does partnership or ownership mean?
- ▪ What are the financial gains and potential financial responsibilities? What is the time commitment beyond standard clinical duties required for partnership or ownership?
In the coming months, I will try to answer these questions by defining each of the three main partnership and ownership categories. I welcome your comments and opinions.