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Do you feel you're losing control over your practice? Read how one family physician has learned to manage both planned and unexpected changes.

Fam Pract Manag. 1998;5(3):59-65

Change is an inevitability few of us like. It's human nature to want to feel safe and secure. Change can threaten our sense of stability and, when the change is unexpected, it can throw us into chaos. Those who thrive on change are the smart planners. They depend on change for movement. They've learned to weather unfavorable situations in their search for something better. Herein lies an important lesson: Change facilitates the pursuit of new opportunities as long as real threats are identified and properly managed.

Physicians are well prepared to cope with change. We have dealt with it in one form or another throughout our lives. We are more financially secure than most of our neighbors. We provide a unique type of service that our society values highly. We are the beneficiaries of a long and proud tradition of professionalism which recognizes that the privilege of being a physician carries a responsibility to act in ways that improve the health of the American people. That having been said, we still must work hard to manage change effectively.

Think before you act

What does your personality type tell you about your ability to manage change? When faced with change, do you carefully scrutinize the situation and then take action or are you more likely to let your emotions dictate your behavior? Do you tend to embrace change, ignore it or try to stop it?

It's important to understand how we deal with change because our reactions may well determine our future successes and failures. The following two examples describe situations in which external forces compelled change and illustrate the importance of assessing a situation thoroughly, developing a realistic and constructive action plan, and then moving ahead with the proper blend of wisdom and courage.

A large insurer that covered 30 percent of a family practice's patients changed from a PPO structure to an HMO model of capitation and risk sharing. Since the physicians had little experience with capitation, they wisely retained the services of consultants to help them review their contracts and negotiate a “win/win” agreement. A comprehensive education plan was implemented for employees of the practice to teach them how best to serve managed care patients. The physicians studied the managed care literature and took some relevant CME courses. The group had previously taken steps to insure that they were practicing high-quality medicine, so no new initiatives in this direction were required. Looking back a year later, the doctors were pleased to find that the transition had gone smoothly and that they were able to do well, both professionally and financially, in the new environment.

A very different outcome was experienced by a highly respected seven-physician group that had contracted to provide coverage in a for-profit community hospital's emergency department with over 30,000 visits annually. When their contract came up for renegotiation, the hospital asked for 10 percent of the group's net collections as payment for overhead costs. The physicians lacked the experience and business skills necessary to deal with this threat effectively, but they did not seek professional advice. During numerous negotiation sessions, they refused to discuss possible financial concessions, insisting that the group keep all physician-generated revenue. On the day the contract lapsed, the group was asked to leave the premises of the hospital. The doctors' professional careers were disrupted and they experienced stress in their personal lives, an outcome that could have been prevented with a more realistic and businesslike approach to the problem.

The situation is different when the decision for change is voluntary. Consider the case of a 43-year-old family physician who had built a stable practice in an attractive suburb of a large city. He became very concerned about protecting his practice in a rapidly changing health care market. Personal financial security and professional freedom were important to him. He was also feeling stressed from long hours of practice and sought a way to devote more time to himself and his family.

His independent practice was running fairly well, but problems with cash flow, accounts receivable and staff turnover persisted. He felt that the time demands of being a small business owner and manager interfered with pursuing his professional and personal goals. The expense of college education for his children was just over the horizon. He had future plans for world travel and wanted to be sure that his retirement was well financed. He worried about the impact of health care changes on his practice. He was discouraged by the control insurers had developed over his patients and the resulting rapid patient turnover. Competitive pressures from other practices in his community were growing.

With all this in mind, he decided to investigate opportunities to associate with a managed care entity in a way that would secure his primary goals. He negotiated with several organizations and eventually focused his attention on an offer to join an integrated health care delivery system. The proposal called for him to turn over his employees and business office operations to the management services organization of the larger entity. He would be placed on a productivity bonus plan similar to the one he had set up for himself in the previous five years. He weighed the risks and benefits and worked with his accountants and attorneys to be sure that the details of the agreement were properly secured by a binding contract. He knew if he decided to sign the agreement, he would go full steam ahead and not look back. If he decided to decline, he would keep his options open, if possible, and establish contacts for future opportunities. By distancing himself enough from his emotional reactions to distinguish the real threats the future held from other changes and from actual opportunities, he managed to get to the point where he could decide his future freely and intelligently.

How best to prepare for change

Clearly, our best defense against the negative effects of change is our personal resources, preparedness and flexibility. Here, then, are some practical pointers for those who face the need to adapt to change in the medical arena.

Keep your finances in order. Physicians who are secure financially are best prepared to be flexible in addressing change. It is better to make long-term decisions from a position of security than in response to a threat to your financial survival. Plan for the possibility of future income decreases by living on less than your current income, making substantial savings investments and choosing debt obligations carefully.

Make your practice as effective and efficient as it can be. Supplying the demand for real and perceived quality and service will usually lead to long-term success. Find out what your competition is doing and figure out a way to do it better. Don't allow ego or monetary concerns to keep you from seeking expert advice about practice management and other crucial issues.

Do a reality check periodically. The secret of mastering change is the ability to direct change within ourselves. What are your long-term goals and ambitions? What feelings are you experiencing in reaction to the external pressures you face? What would have to change in your professional life to bring it into harmony with your beliefs and feelings? Are you an impulsive person who needs to learn the value of caution, or an overly cautious one who should strive to be more assertive and proactive? Can you manage feelings of frustration, anger and anxiety without “turning off” the people around you? Have you fallen into the error of believing that being a doctor means you are an expert in everything, or do you know your limits and when to ask for advice? It is extremely important to set goals and stick to them and to learn to channel your emotions into positive energy.

Make informed decisions. Learn from your mistakes and those of others. Seek the advice of qualified consultants when making major decisions. If you're considering new or different business relationships, find out as much as you can about the organization and the individuals before you act. Should you decide to decline an opportunity, keep the lines of communication open. Tactfully leaving an offer on positive grounds will preserve relationships.

Expand your knowledge. Set aside time for learning. Enroll in courses sponsored by the AAFP, American College of Physicians, American College of Physician Executives, Medical Group Management Association and other organizations. Also take advantage of opportunities for self-study.

Learn to work effectively with people and organizations. If you're not currently involved in an integrated delivery system, there's likely to be one in your future. Determine what it will take to become more organizationally savvy. Develop your “networking” skills and share ideas and information with professional colleagues and with administrators. Look for people who share your goals and perspective. Learn to give and take, but never forget that personal integrity is essential both to organizational relationships and to your role as a professional.

Consider your adversaries. Get to know the business leaders and administrators whose goals and values are having such an impact on health care today. Avoid complacency and be prepared to negotiate realistically. Beware of divide-and-conquer tactics. Find ways to assert your ethical values in a for-profit arena.

Be proactive. Anticipate trends and move ahead while time is in your favor. Change that you create can be your opportunity to lead and to manage, while change controlled by others is likely to become a burden for you. Remember, though, to monitor the results of your actions and to watch for newly emerging factors that may lead you to alter your course in midstream.

Obviously not all change is good for us. Like a sailor who is dependent on the wind to move his vessel, we must be realistic about where the air is coming from and how hard it is blowing. We must also plan for hidden obstacles between our present position and our destination, and factor in the design and seaworthiness of our vessel. Our sails must be trimmed in response to a realistic assessment of prevailing and anticipated conditions, not to wishful thinking. Some situations can be changed but others cannot, and knowing the difference is essential to professional survival. Even seemingly hopeless predicaments can be made more tolerable by those who will study the facts carefully, work for improvement and become tolerant of the inevitable.

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Copyright © 1998 by the American Academy of Family Physicians.

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