Play by the Rules

John Nelson, MD, FACP

How does your hospitalist group make decisions on important issues? There are many reasonable approaches. The best method will vary significantly depending on the group’s size and whether the doctors own their own private practice or are employees of a hospital or large multisite private hospitalist group.

Because many doctors are drawn to the profession in part seeking autonomy and independence, there is often a tension between their desire to make many decisions about business and practice operations independently and the need to set aside some personal interests in order for the group to function well. This can become apparent when the group reaches an agreement regarding a difficult issue for which there are different points of view.

Consider a hospitalist group made up of internists occasionally asked to admit teenagers younger than 17. There might be a variety of opinions about whether this is appropriate, but it will be best for everyone in the group to follow the same policy. If the majority decision is that it is reasonable to admit patients as long as they’re post-pubertal, everyone in the group should abide by this policy.

But when called by the emergency department about such a patient, a dissenting hospitalist might feel entitled to decline the admission despite the group’s decision. For this doctor, autonomy trumps cohesive group functioning.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

The best approach to individual doctors not feeling bound by the group’s decisions is complex and will vary depending on the situation. But it can be mitigated by ensuring that the group has a clear governance structure and method for reaching controversial decisions.

Group Size Matters

A look at hospitalist groups of varying sizes illustrates the growing complexity of decision-making processes.

Small groups (eight or fewer individuals): Hospitalist groups nearly always start with a small number of doctors (often between one and three at the group’s inception) and find little need for a formal governance structure. They tend to make all important decisions based on consensus.

One risk of making decisions by consensus is that the group may be limited by the lowest common denominator. Even if most doctors in the group want to change something to avoid disadvantaging a doctor with a different point of view, the group may be held back and not make the change. In essence, the group can be ruled by the minority. This may not happen often, and as long as the group keeps this risk in mind it is usually fine to operate on consensus.

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