In part two of this response, I focus on the systemic issues involved when considering the replacement of a medical director in the emergency department and what to do about them.

Part Two: Removing the Obstacles

When considering whether to replace the EDMD, look for procedural, financial or organizational impediments to leadership performance. What historical circumstances or established expectations are limiting the person in this position. If barriers exist, it’s doubtful that the new doctor will be any more effective, even if you proceed with the transition.

Common barriers to success for EDMDs

CMG Interference

If you have a contract with a CMG, the local coverage physicians may believe or have been told that any new ideas or innovation for the ED is supposed to come from Corporate Headquarters. The division of responsibility between a local Medical Director and the CMG’s Regional or National Medical Director is often poorly defined, allowing for individual initiative but frequently resulting in confusion about assignments and authorities.

Limited Exposure

There are multiple reasons why a Medical Director fails to offer the desired initiative or innovation. In some cases it’s that, “they don’t know what they don’t know.” If the local doctors aren’t active in the American College of Emergency Physicians (ACEP), regularly attending ACEP’s Scientific Assembly and/or the Medical Director hasn’t attended or isn’t enrolled in ACEP’s Medical Director’s Academy, they may not be aware of the “best practices” of the specialty.

Insufficient Compensation

Often the membership of local groups fails to fully appreciate and adequately value the administrative tasks and responsibilities. As such, many EDMD’s have not been allocated sufficient time and/or adequate compensation to effectively perform their administrative duties. And, it isn’t just the local groups, CMG’s often target administrative compensation when they’re trying to “sharpen their pencils” in a competitive bid situation.

Start with the basics; how is the leadership physician paid? Is it just a bump in the clinical salary or hourly rate, or is there a dedicated stipend for the administrative duties?  If there’s a stipend, how was it established? Divide the stipend by the current clinical hourly compensation to determine the number of administrative hours “budgeted.” Or divide the stipend by the your expectation of dedicated administrative time to get an “estimate” of the hourly rate for the EDMD’s non-clinical time.

Not Enough Time

How do the total of the EDMD’s clinical plus administrative hours (actual, if you know it or using the estimate above) compare to the number of clinical hours provided by the other members of the group? If he’s working more total hours than his colleagues, it could be that he’s not receiving a dedicated stipend or its not sufficient, or because he’s trying to boost his income or because he’s the one who gets stuck filling all of the open shifts. Regardless, his administrative duties are certain to suffer!

Speaking of adequate time, if your ED is seeing more than 50,000 annual visits, the EDMD duties should require a full-time equivalent (FTE). So that the Director can continue to practice clinically, some of the duties should be assigned to the Assistant EDMD. The EDMD works 75% of his time administratively and 25% clinically. It’s the reverse of that for the Assistant. Lower volume departments may be able to get away with less than a full FTE but rarely can the leadership function be performed without the EDMD being allocated and compensated for at least 40 administrative hours a month.

If after completing the research and discussions, you still have the opinion that the new physician needs to serve as the EDMD, consider a transition period.

No Succession Planning

“Suggest” that the contract group develop a succession plan and that their 1^st step might be to create a 2^nd or even 3^rd Associate or Assistant EDMD position.  Then encourage the group to install the EM Residency Trained/Boarded Physician in that new position.  In doing so, be sure that the doctor is afforded adequate time to perform his administrative duties and is compensated so he’ll/she’ll be motivated to commit the time (and be willing to give-up clinical shifts) to do so.

If it’s not clear that the EDMD should be removed, that decision doesn’t mean that you have to continue to accept substandard level administrative services.

Undeveloped Leadership Skills

As you know, few physicians have any formal training in administrative duties or leadership. If the EDMD isn’t already attending ACEP’s Medical Directors Academy, strongly encourage him/her to do so.

No One to Talk To

Additionally, consider securing the services of an Executive Coach to assist the EDMD in the development of leadership, communication and dispute resolution skills. Make the Executive Coach a part of the transition plan so the Assistant EDMD, if and when there is one, gets the training as well. And if you’re determined to install the Residency Trained Physician as the EDMD, you’re advised to make every effort to insure that he’s successful in the role. With no experience in a leadership role, the new EDMD will have even more to gain from an Executive Coach.

Final Thoughts on Removing the Medical Director

If your contract is with a CMG make it clear that you want and expect more effective leadership and innovation from your ED Physicians.  While you’re at it, be sure that the management company agrees to give the local doctors both the specialized support and the authority to deliver that leadership.

If your contract is with a local coverage group, encourage them to consider securing professional management.  In selecting that management service the local group should be sure that the management firm has the specific talent, resources and experience needed to support the physician leadership.

Finally, if the decision is made to “remove” the existing Medical Director in favor of the EM Residency Trained Physician, make every effort to “soften the blow.”  Even if his performance hasn’t met every expectation, the current EDMD deserves to be acknowledged and his efforts applauded.  You’re advised to start the transition in private but finish it in a very positive and public manner.