Every health care organization has a board of directors (sometimes known as a board of trustees or governing body) that sets policy, hires the chief executive officer (CEO), sets the annual budget, approves large purchases, plans for the future and bears legal accountability for the organization's financial soundness and service delivery. That board should include at least one family physician. Maybe it should be you.

The boardroom may seem distant from the exam room, but it's not. Many board decisions directly affect your daily work and livelihood, either positively or negatively. For example, gag orders — requirements that a managed care organization's (MCO's) physicians not recommend certain tests or procedures that might hurt the organization's profit margin — have become notorious. But they might never have seen the light of day had MCOs included front-line physicians on their boards from the beginning.

Of course, having a family physician on the board helps an organization do more than play defense. The input — and the vote — of a family physician is critical in helping to make decisions that will be in the best interests of patients on a wide variety of issues. Consider these examples:

• Should an MCO focus on being a managed care organization or on becoming a genuine integrated delivery system? The former means the organization's primary concern will be exploiting the current profit-taking U.S. health care policy to maximize return for investors. The latter means the primary concern will be providing a wide range of health care services in a way that is convenient and affordable for the public (and, by the way, doing very well economically because of the public's positive response).

• Does the organization have a written policy defining the primary purpose of physician credentialing? If so, does it emphasize the original purpose of credentialing — to protect patients — or does it reflect the use of credentialing as an economic tool, one that builds a medical staff of high-revenue producers?

• What is the board's policy about responding to public or payer demands for accountability, such as physician “report cards”? Some methods of reporting physician data are useful to the public and fair to doctors. Others are neither. Sometimes, only the eye of a clinician can discern which methods are which.

Should it be me?

Clearly, front-line physicians should have a place at the table when their organizations' boards meet. But should that expert in day-to-day clinical care be you?

Here's one way to determine whether you're board material. Imagine that you're taking part in a meeting of condominium owners. Some of the owners really don't want to be bothered with the activities of the condo association. They don't particularly care about setting rules for use of the pool. Whatever budget the condo board sets is OK with them. If additional assessments are levied, they're willing to pay. But other owners take a personal interest in the governance of their association. They find out how to become part of the board that establishes the budget and makes the rules.

If you're the first type of condo owner, then you may not be interested in being on the board of your health care organization. You may feel that things are fine as long as you're left alone to practice medicine. But if you're the second kind of condo owner, you're probably an excellent board candidate.

How can I get on the board?

The first reality to recognize is that you can't get on the board unless the organization's bylaws provide the opportunity. Your bylaws may well not mandate that the board include a certain number of family physicians. But the bylaws shouldn't exclude interested and qualified frontline physicians from consideration.

Your first step should be telling the medical director or CEO that you're interested in serving on the board. They won't know if you don't tell them. And they might welcome you with open arms, if not as a board member immediately then as a member of a board committee. That's a start.

There's always the possibility that the welcome may not be so warm. In some situations, CEOs, board members or the organization's lawyers may put up roadblocks to keep you — or any frontline physician — off the board. How to deal with that is a topic for another article; suffice it to say here that you should focus your efforts on persuading the source of the opposition (rather than trying to rally your supporters to lean on him or her), pointing out organizational rules and accrediting-body standards that support your desire to serve.

How can I contribute?

Once you've gained a position on your organization's board, how will you go about making a difference there? For the most part, you can just be yourself — as long as that means being objective and fair, having good analytical skills, speaking and writing well, and being willing to spend the necessary time to fulfill your obligations as a board member. “Necessary time” includes attending meetings of the board and any committees to which you're assigned, as well as taking time to review and frame good questions about the materials sent to you before meetings.

Also, you must be willing and able to participate in discussions following the model of brainstorming — that is, bringing up ideas that help board members consider all possible alternatives without expecting the board to embrace every suggestion you make. Once a vote has been taken, you must be ready to work to bring about a positive outcome for whatever proposal the board has chosen.

Above all, wear the right hat to the board meeting; leave your own agendas at the door. Your role is not that of a fierce advocate for family practice or for your own group of physicians. Remember that truth, like love and sleep, resists an approach that is too intense. You will serve family practice, and yourself, best if you join with others in dealing with the board's agenda, which is to meet its double-edged responsibility for ensuring the organization's financial success and the quality of the service it delivers. Of course, you'll want to point out, occasionally, that achieving those goals is impossible without adequately supporting and rewarding the organization's salaried family physicians or without providing the best medical care possible.