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Fixing broken practice boards takes care, consideration of many factors
Similar to treating a patient with an illness, repairing a broken practice board requires the right diagnosis.
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“Happy families are all alike; every unhappy family is unhappy in its own way.”
– Anna Karenina, Leo Tolstoy
Practice boards, whether composed of two doctors in a modest partnership or 20, are susceptible at every turn to unresolved disagreements and unhappiness. Boards can periodically bend out of shape, and many eventually “break.”
Why? Like Tolstoy, we can observe that there are numerous kinds of wedges driven between practice partners who sit on unhappy boards.
Most wedges, in the end, are ultimately economic in nature, although they may be masked in more seemly terms:
“I need this new laser not just to help my segment of the practice, but to keep us up with the local standard of care.”
“Think of the prestige our practice will enjoy if I take on this new research study.”
“My surgical outcomes will suffer if my packs don’t contain a left-handed titanium transnasal retractor.”
Jealousies, petty or otherwise, are a common wedge. These take many forms. Senior doctors may be jealous of up-and-coming junior partners, who they see as having not yet paid sufficient dues. Doctors whose subspecialties limit them to more modest billings can be jealous of their more prosperous colleagues.
Conflicts can sometimes arise over a perception that there is an unfair distribution of responsibilities.
“As the senior partner, I seem to be the only one who cares about this place. My production suffers because I spend 8 hours a week on staff problems without a word of thanks, while you all sit back and generate more income for yourselves.”
Sometimes disharmony is generalized. There is no prominent disagreement, but rather an accretion of past hurts and controversies. “Old shoe syndrome” can set in, and like longtime spouses, long-term partners will progressively gnaw on each other. The cordiality and social bounds they once respected fall away, exposing pent-up hostilities. Once close friends can no longer stand to be in the same room.
And of course, there is the human factor. Not everyone can get along with everyone else. Underlying personality issues — prominently in the profession: narcissism, bipolar disorder, generalized anxiety — can stand in the way of harmony. In the toughest settings, underlying interpersonal conflicts are magnified by any real or looming economic difficulty.
Board conflicts on the rise
After 35 years in the field observing practice boards first hand, I can report that board conflicts appear to be on the rise. I believe there are four key reasons for this.
Most prominently, profit margins are narrowing. Abundance can paper over a lot of interpersonal conflicts. Back in the days of high fees, low competition and 50% profit margins, it was hard for arguments about money to break out. In addition to robust personal incomes, there were very few high-ticket decisions. No six-figure computer decisions. No half-million dollar femtosecond laser quandaries.
Next, practices are getting more diverse. Intergenerational conflicts arise naturally, of course, but there is more. Twenty years ago, most eye surgeons were white, boomer, workaholic 40-something men with scant work-life balance. Ophthalmology was a pretty clubby world. Today the age, gender, ambition and ethnicity distribution bandwidths are all much wider, which is a natural set-up for more board conflicts.
Of course, practices are getting larger and more complex. This cuts several ways. Decisions are larger and harder. One wrong move can be much more expensive. The decision cycle is slower because more facts have to be gathered to come to a decision. And in large, complex practices, implementation is frustratingly slower, so problems can linger.
And finally, everyone is getting appropriately more anxious about the future. Even if you work in a well-run, harmonious setting today, you and your fellow owners who are projecting gloom about lower payments and higher regulatory controls naturally exacerbate shareholder frictions.
Healthy ophthalmic practice board
To recognize potential board pathology in your practice, it helps to consider the hallmarks of a healthy medical practice board. Here are a few:
- Wise choices are made regarding who is admitted to partnership. Economic productivity, alone, is not a ticket to practice ownership.
- Disruptive individuals are speedily removed from the board, and perhaps from the practice itself.
- Healthy practice boards work from well-documented governance rules, especially those rules regarding thresholds for decision making, tie-breaking mechanisms and an appeal process for doctors who are frustrated by a board decision that did not go their way.
- Powerful, effective practices are run by powerful managing partners who have sufficient tenure and appropriate operating latitudes, and who are given tough, regular feedback on their performance.
- Powerful managing partners cannot shine without competent administrators, and vice versa. Board squabbles commonly center on frustrations because they perceive that the lay management team is not hitting reasonable goals.
- In harmonious board settings, we see a sufficiency — even an abundance — of meetings. For the typical practice, the board should meet monthly. The administrator should be present; sometimes with a vote, always with a strong voice.
- Lastly, great practices are great to the extent that they foster a culture where fearless confrontation of any open issues is the norm.
Repairing broken boards
While each unhappy practice board may be unhappy for different reasons, the path back to normalcy is uniformly analogous to a sick patient’s path back to health.
First, someone on the board has to feel a visceral chief complaint and be sensitive enough to be the first to speak up. That person needs to communicate their concerns, even if mild and still “subclinical,” to other board members. For example, “Mike, I’m a little disturbed by events at our last board meeting. We normally show a lot more respect for each other’s opinions, but several of us really tore into Bob. This seems to be a growing pattern. I’m afraid if this keeps up, we’re going to have a hard time making effective, collaborative decisions.”
Next, just as in medicine, you need to seek the right kind of treatment. Some gaps in board functioning are self-resolving, like the common cold. Other gaps, wider ones, need professional help.
More group discussion alone, moderated by the board chair or practice administrator, may be enough for board members to walk back from the brink of discord. If that is not enough, you may need an expert. What kind of expert depends on the situation. If you have a focused practice issue, analogous to a patient’s focused clinical complaint, calling in an expert in that area may be all that is needed.
Let us say a board fight has been brewing about your office facility. Half of the board wants to update the building. The other half of the board wants to spare costs. Bringing in a medical space planner or architect could help to break the tie. A fresh exterior might be feasible for less cost than was feared, or more cost than was hoped.
Resolving an acute, fresh and focused controversy of recent origin can be simple. It is much tougher when positions have hardened. For these long-standing board conflicts, a different, deeper kind of facilitation may be needed:
- A forensic accountant in the case of suspected mismanagement of funds.
- A trusted attorney who can help to unravel and revise outgrown shareholder agreements.
- An industrial psychologist to gain insights about frank interpersonal conflicts.
- A specialist billing, ASC, managed care or similar consultant to help break a tie vote on one technical point or another.
And here is a closing thought, again analogous to medicine. Just as diabetic patients have a chronic disease they must manage for life with good habits and ongoing medication, some boards are chronically discordant. Just as a type 1 diabetic may need daily insulin for life, some boards need strong, regular medicine to remain healthy: extra meetings, formal leadership development and the regular attendance of a trusted non-owner moderator or outside board member to help referee meetings that would otherwise spin out of control.