Question: Our Emergency Department Medical Director (EDMD) is one of the original members of our Emergency Medicine Practice. He’s primary care trained like most of our Emergency Physicians and is Emergency Medicine Board Certified but not by the American Board of Emergency Medicine. He’s practiced clinically here for years and has been the EDMD for most of that time.

Two years ago the first Emergency Medicine Residency Trained Physician began working in our ED. He’s energetic, enthusiastic, and ambitious. He’s impressed the department’s nursing leadership and staff, and they’re encouraging administration to have him designated as the ED’s Physician Medical Director (EDMD).

Our contract for ED Physician Services says we have approval over who serves as the Medical Director so we appear to have the authority to compel the change. How do you recommend that we proceed?

Answer: There are few things as potentially disruptive to the stability of an Emergency Physician Staffing Contract as the turnover in the Medical Director position. Whether your contract is with one of the Multi-Hospital Contract Management Groups (CMG’s) or with a local, independent practice, the departure of the Medical Director is almost certain to create waves. And the more the hospital appears to be responsible for that departure, the larger the waves can be.

That isn’t to say that a change can’t or shouldn’t be made. On the contrary there may be ample reason to take action. But before you began any effort in this regard, realize that there are likely to be complications—potentially serious ones.

Given the complexity of this situation, the response will be in two parts.

Part One: Costs and Complications

• Medical Director may leave
  At a minimum, a forced removal could result in the loss of the current Medical Director. Even if you’re not happy with his/her performance in an administrative role, are you prepared to lose his clinical contribution as well?
• CMG Objections
  Your CMG could also object! If you insist that they remove the EDMD, the firm may not be able to find a suitable replacement in a timely manner or may want to reopen contract negotiations if they do.
• Coverage Doctor Exodus
  Some or all of the other coverage doctors could join him or at least threaten to do so. That could certainly get the medical staff’s, the board’s, even the community’s attention. Are the reasons for making the change sufficient to warrant having to overcome resistance of that kind?
• Mass Exodus
  The reaction of a local practice, especially one that places considerable importance on their autonomy, could be even stronger. The threat of a mass exodus isn’t unprecedented, and the costs and complications associated a rush to replace them, can be enormous.
• Power Struggle
  Even if the group agrees to your request, you may discover that the reassignment doesn’t actually achieve any real transfer of authority. Today’s real leader of the local practice may be the Medical Director but after the forced change, the real power may reside with a newly designated President of the Practice. And that failure to recognize the authority of the new Medical Director can happen even without the creation of a new leadership position. The group members either individually or collectively simply fail to commit to the new Medical Director and actively or passively resists his initiatives. That reality may not be evident until the new EDMD quits in frustration because he can’t get the support and cooperation of his colleagues.

Given the potential complications, it is advisable for administration to be certain that there is a substantive basis for the change. Here are some questions to consider before making a move toward this important change.

• Justification
  Is this change for change’s sake or are their legitimate reasons to do so?
• Scope of Support
  Is it just the ED Staff or hospital personnel that perceive the problems? How about the Medical Staff or the ED Group? Some inquiry (either by you or by a consultant hired to evaluate ED services) may reveal that the membership of one or both is dissatisfied with the EDMD’s leadership and welcome a change!
• Self Awareness
  Is the current Medical Director aware that his services are thought to be inadequate? Has the ED Nurse Leadership or his senior management liaison discussed the need for him to evolve as the Medical Director, and how interested is he/she in doing so?
• Stepping Up
  Is he willing and able to “step-up” his game or really even interested in being the Medical Director? It’s certainly not unheard of for an EDMD to be a reluctant volunteer, who only took the job because no one else would. However, even if he’s not really committed to retaining the position, you’re advised to proceed with caution. As administrators know from experience, doctors (and not just the ED staff) can get their “dander up” if there’s a perception that administration is meddling in the affairs of physicians.

In part two of this response I will cover systemic issues—the operational factors that can restrain the effectiveness of an EDMD—and what to do about them. Stay tuned.