Invited Perspective
Realizing Strength From Our Diversity David Bagnall, MD The most significant hurdle an association faces is the same that is faced by any society: members setting expectations through their own world view. To succeed, both an association and a society must thrive despite diversity. As with any societal structure, an association maintains strength when its members accept the value of compromise. Unlike a geopolitical society, however, membership in an association is usually a choice. So the question becomes, how does an association attract potential members who are free to decline its membership? There is no single answer, but I want to focus on a few of my own impressions while I served on the American Academy of Physical Medicine and Rehabilitation Board of Governors. Let us start with the most evident disparity: there are Academy members who are independent and working outside a local administrative system, and there are others who work within a local system. A physiatrist with the insecurity and freedom of a private practice is no less comfortable than the physiatrist who lives within the secure but restrictive boundaries of a more highly administered system. Both have issues unique to their own situation, and neither typically spends much time pondering the perspective of the other. Thankfully, regardless of their global perspective, most physiatrists share the same goal: to provide the most efficient means of improving a patient’s ability to function. Could this simple division of practice circumstance and perspective contribute to the Academy’s ongoing struggle to maintain membership? With a few notable exceptions, the Academy has historically been guided by physiatrists employed by institutions. By nature, the Academy is itself an institution with an administrative hierarchy. Institutional physiatrists are often incentivized by their employers to participate in national organizations as a means of career advancement, and, unlike private practitioners, physiatrists who work within such a system are frequently more comfortable with an institutional structure as that of the Academy. Private practitioners appear to be less tolerant of administrative interference than their institutional colleagues. They spend most of their professional time making decisions that affect their own highly focused realm; rarely do they need to compromise on issues other than the political and marketing decisions that directly affect their unique practices. Furthermore, private practitioners, despite their significant proportion of Academy membership, have not been as involved with leadership as have their institutional colleagues. These 2 viewpoints constitute a conundrum for the Academy. By design, the Academy must err on the side of systems rather than individuals. But, if the questions posed by and to the Board of Governors are limited to a largely systemic and national perspective, then the outcome will frequently fail to address issues important to individual, noninstitutional members, especially those who do not find such a communal perspective relevant. The Academy Board of Governors has continually struggled with this problem. Associations have a limited capacity to speak to a diverse mix of providers that here-to-fore has conveniently been perceived as monochromatic. It has been my experience that, rather than a reflection of poor leadership, it is a reflection of the historical structure and limitations of associations and of human nature. I believe there are 2 assumptions that perpetuate that limitation: the Academy’s predominately top-down structure and its focus on federal issues. First, the structure of the Academy, or any association for that matter, is problematic because it, like most organizations, places control in the hands of a few well-meaning individuals. We are all biased, confirmed every day in our clinical realms. Our practice decisions reflect the environment we occupy. That bias cannot be left at home when one PM&R 1934-1482/14/$36.00 Printed in U.S.A.
D.B. Private practice, Amherst, NY. Address correspondence to: D.B.; e-mail: bagnall@ rehabny.com Disclosure: nothing to disclose
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 863-865, October 2014 http://dx.doi.org/10.1016/j.pmrj.2014.09.001
863
864
Bagnall
attends an Academy Board of Governors meeting. In fact, we would not want that viewpoint left completely out of Academy decisions, because one’s experience, especially if one is successful, is valuable to an association. However, we hope that Board members are aware of their biases and that the Board is composed of members who reflect the diversity of Academy membership. Generally, this is a hope fulfilled. However, it has become more apparent that a decision process founded on a group of interested physiatrists meeting multiple times a year is philosophically and structurally problematic for several reasons:
Those of us interested in having a greater impact intend nothing but the best when we make grand decisions that affect others. This is a weakness of any top-down governance structure. In reality, a group of leaders cannot know what is best for an individual. There is a tendency, even an obligation, to be generic, which limits the ability to address the multiple flavors demanded by its members, especially within the limited national perspective of the Academy’s mission. There is misplaced hope by the Board that it can influence the decisions of carriers and governmental agencies to act logically when the system prevents implementation of logic. There is the unpleasant reality that, regardless of the decision made by leadership, a measurable number of members will be aggravated by that decision. I believe Board members must continually remind themselves of their limitations and avoid the temptation to wander down specific paths unconsciously guided by their own biases to govern. Indeed, the role of the Board is as much as possible to create an infrastructure that allows individual Academy members the opportunity to create their own unique value from Academy membership. Secondly, there is a larger factor that influences the way that the Academy views and pursues its mission. The Academy typically directs its focus on federal initiatives. In fact, the Academy has concentrated an enormous effort on recent federal health care mandates, sincerely presuming that resources spent elsewhere are misspent. For many years, the Board has directed its strategic planning toward how to fit within the paradigm it believes is mandated by Washington. This has opened some interesting and potentially fruitful opportunities, especially regarding outcomes research and best practices; information every physiatrist would find valuable, regardless of his or her practice setting. The Academy has made a significant investment in building a structure to address and nurture those opportunities. But, even as its federal aims can be understood, this national focus greatly limits the Academy’s ability to speak to matters of equal importance to its members, that is, local issues. Private practitioners are influenced more significantly by local reimbursement and oversight systems, whereas a greater number of institutional practitioners are affected by the federal system.
STRENGTH FROM DIVERSITY
One can argue whether the federal health care system will survive its recent reconstitution, whether nonfederal systems will mimic or eschew its structure, and the degree to which physicians, particularly private practice physiatrists, will alter their practices to minimize their participation in the federal health care system. One cannot argue that the federal system is the only practice option available to Academy members. I continue to believe that the Academy maintains relevance by extending its voice to include practitioners in regional settings and private practices. Most physiatrists generate a greater portion of their revenue and have a larger personal stake in private carriers, state systems, and free market reimbursement. Furthermore, to assume that private and local health care systems will eventually follow the federal structure ignores the overwhelming flaws in that structure. There are many practitioners around the country who generate most of their income outside the Medicare, Medicaid, and the Veterans Affairs systems. They provide services to patients injured in state-specific workers’ compensation and no-fault systems. They provide nontraditional services, such as peer review, independent medical examinations, disability determination, life care planning, and expert testimony. These members are creating new markets that use their skills beyond the obvious and generate other feefor-service products. In short, the Academy misses an opportunity when it wrings its hands in fear of failing to provide guidance to its members relative to the federal system. The Academy has the means to provide value to those members. Our technological capacity for physiatrists of like concerns to aggregate and communicate is enormous. The Academy has made a strong effort to increase its value to individual members. The council structure and PhyzForum have been two such endeavors. Although there have been frustrations with both of those entities, in fact, they have increased the voice of singular clinicians attempting to find common relevance and experiences with others facing similar hurdles. The future of generic associations is unclear. On a global stage, our means of interacting has evolved. The way we receive our news and information; communicate; enjoy music, literature, and films; and manage our finances extend beyond what our nascent minds could have imagined. Many would argue that our current system of national and state governance is outdated, so should we be surprised that an association such as the Academy continues to search for the rails of a new direction? An Academy saturated with members gains strength and greater influence on the issues that affect individual physiatrists in each of their specific geographic locations and clinical focuses. The past several decades document the enormous power of individuals who contribute to shared experiences with crowdsourcing in almost every area of life, from the arts, to business, to philanthropy. I suspect members would feel greater confidence by belonging to an Academy more fully permeated by physiatrists, receiving what they want and need in the form of clinical education, advocacy, income security, and camaraderie.
PM&R
So, beyond the governance structure of the Academy, we also must examine ourselves as members. In an ideal situation, every physiatrist would contribute to the Academy to keep it financially and philosophically sound. Still, 30% of our colleagues do not associate the tangential value of the Academy with their personal responsibility to support it. Fortunately, all but the most self-absorbed recognize the limitations of the Academy to respond to their specific needs. We tend to understand the value of compromise and the notion of the greater good. Furthermore, most of us realize the value of belonging to multiple organizations, peeling off just what we need from each one to create a structure that meets our precise needs. The Academy must continue to recognize not only its national but also its local responsibilities. Getting caught in
Vol. 6, Iss. 10, 2014
865
the political uproar has finite value. The Academy is responsible to members’ needs, not just members’ national needs. This distraction will lead to missed opportunities, which, even as they might be hidden, can be tangible losses. The Board of Governors is perhaps the most effective structure that we have to help guide the Academy’s decisions, but we must be aware of its limitations. The Board is made up of imperfect humans with presumptions and viewpoints that are unique. Board members must remain vigilant to their biases and how they impact decisions. They must find humility in a position that risks vanity. As members, we should all assess our expectations of the Academy, viewing it not as an answer to all of our needs but as an entity that requires nurturing by each of us. It remains the best structure we have to promote the values of our specialty and our ability to serve our patients.
Realizing Strength From Our Diversity David Bagnall, MD The most significant hurdle an association faces is the same that is faced by any society: members setting expectations through their own world view. To succeed, both an association and a society must thrive despite diversity. As with any societal structure, an association maintains strength when its members accept the value of compromise. Unlike a geopolitical society, however, membership in an association is usually a choice. So the question becomes, how does an association attract potential members who are free to decline its membership? There is no single answer, but I want to focus on a few of my own impressions while I served on the American Academy of Physical Medicine and Rehabilitation Board of Governors. Let us start with the most evident disparity: there are Academy members who are independent and working outside a local administrative system, and there are others who work within a local system. A physiatrist with the insecurity and freedom of a private practice is no less comfortable than the physiatrist who lives within the secure but restrictive boundaries of a more highly administered system. Both have issues unique to their own situation, and neither typically spends much time pondering the perspective of the other. Thankfully, regardless of their global perspective, most physiatrists share the same goal: to provide the most efficient means of improving a patient’s ability to function. Could this simple division of practice circumstance and perspective contribute to the Academy’s ongoing struggle to maintain membership? With a few notable exceptions, the Academy has historically been guided by physiatrists employed by institutions. By nature, the Academy is itself an institution with an administrative hierarchy. Institutional physiatrists are often incentivized by their employers to participate in national organizations as a means of career advancement, and, unlike private practitioners, physiatrists who work within such a system are frequently more comfortable with an institutional structure as that of the Academy. Private practitioners appear to be less tolerant of administrative interference than their institutional colleagues. They spend most of their professional time making decisions that affect their own highly focused realm; rarely do they need to compromise on issues other than the political and marketing decisions that directly affect their unique practices. Furthermore, private practitioners, despite their significant proportion of Academy membership, have not been as involved with leadership as have their institutional colleagues. These 2 viewpoints constitute a conundrum for the Academy. By design, the Academy must err on the side of systems rather than individuals. But, if the questions posed by and to the Board of Governors are limited to a largely systemic and national perspective, then the outcome will frequently fail to address issues important to individual, noninstitutional members, especially those who do not find such a communal perspective relevant. The Academy Board of Governors has continually struggled with this problem. Associations have a limited capacity to speak to a diverse mix of providers that here-to-fore has conveniently been perceived as monochromatic. It has been my experience that, rather than a reflection of poor leadership, it is a reflection of the historical structure and limitations of associations and of human nature. I believe there are 2 assumptions that perpetuate that limitation: the Academy’s predominately top-down structure and its focus on federal issues. First, the structure of the Academy, or any association for that matter, is problematic because it, like most organizations, places control in the hands of a few well-meaning individuals. We are all biased, confirmed every day in our clinical realms. Our practice decisions reflect the environment we occupy. That bias cannot be left at home when one PM&R 1934-1482/14/$36.00 Printed in U.S.A.
D.B. Private practice, Amherst, NY. Address correspondence to: D.B.; e-mail: bagnall@ rehabny.com Disclosure: nothing to disclose
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 863-865, October 2014 http://dx.doi.org/10.1016/j.pmrj.2014.09.001
863
864
Bagnall
attends an Academy Board of Governors meeting. In fact, we would not want that viewpoint left completely out of Academy decisions, because one’s experience, especially if one is successful, is valuable to an association. However, we hope that Board members are aware of their biases and that the Board is composed of members who reflect the diversity of Academy membership. Generally, this is a hope fulfilled. However, it has become more apparent that a decision process founded on a group of interested physiatrists meeting multiple times a year is philosophically and structurally problematic for several reasons:
Those of us interested in having a greater impact intend nothing but the best when we make grand decisions that affect others. This is a weakness of any top-down governance structure. In reality, a group of leaders cannot know what is best for an individual. There is a tendency, even an obligation, to be generic, which limits the ability to address the multiple flavors demanded by its members, especially within the limited national perspective of the Academy’s mission. There is misplaced hope by the Board that it can influence the decisions of carriers and governmental agencies to act logically when the system prevents implementation of logic. There is the unpleasant reality that, regardless of the decision made by leadership, a measurable number of members will be aggravated by that decision. I believe Board members must continually remind themselves of their limitations and avoid the temptation to wander down specific paths unconsciously guided by their own biases to govern. Indeed, the role of the Board is as much as possible to create an infrastructure that allows individual Academy members the opportunity to create their own unique value from Academy membership. Secondly, there is a larger factor that influences the way that the Academy views and pursues its mission. The Academy typically directs its focus on federal initiatives. In fact, the Academy has concentrated an enormous effort on recent federal health care mandates, sincerely presuming that resources spent elsewhere are misspent. For many years, the Board has directed its strategic planning toward how to fit within the paradigm it believes is mandated by Washington. This has opened some interesting and potentially fruitful opportunities, especially regarding outcomes research and best practices; information every physiatrist would find valuable, regardless of his or her practice setting. The Academy has made a significant investment in building a structure to address and nurture those opportunities. But, even as its federal aims can be understood, this national focus greatly limits the Academy’s ability to speak to matters of equal importance to its members, that is, local issues. Private practitioners are influenced more significantly by local reimbursement and oversight systems, whereas a greater number of institutional practitioners are affected by the federal system.
STRENGTH FROM DIVERSITY
One can argue whether the federal health care system will survive its recent reconstitution, whether nonfederal systems will mimic or eschew its structure, and the degree to which physicians, particularly private practice physiatrists, will alter their practices to minimize their participation in the federal health care system. One cannot argue that the federal system is the only practice option available to Academy members. I continue to believe that the Academy maintains relevance by extending its voice to include practitioners in regional settings and private practices. Most physiatrists generate a greater portion of their revenue and have a larger personal stake in private carriers, state systems, and free market reimbursement. Furthermore, to assume that private and local health care systems will eventually follow the federal structure ignores the overwhelming flaws in that structure. There are many practitioners around the country who generate most of their income outside the Medicare, Medicaid, and the Veterans Affairs systems. They provide services to patients injured in state-specific workers’ compensation and no-fault systems. They provide nontraditional services, such as peer review, independent medical examinations, disability determination, life care planning, and expert testimony. These members are creating new markets that use their skills beyond the obvious and generate other feefor-service products. In short, the Academy misses an opportunity when it wrings its hands in fear of failing to provide guidance to its members relative to the federal system. The Academy has the means to provide value to those members. Our technological capacity for physiatrists of like concerns to aggregate and communicate is enormous. The Academy has made a strong effort to increase its value to individual members. The council structure and PhyzForum have been two such endeavors. Although there have been frustrations with both of those entities, in fact, they have increased the voice of singular clinicians attempting to find common relevance and experiences with others facing similar hurdles. The future of generic associations is unclear. On a global stage, our means of interacting has evolved. The way we receive our news and information; communicate; enjoy music, literature, and films; and manage our finances extend beyond what our nascent minds could have imagined. Many would argue that our current system of national and state governance is outdated, so should we be surprised that an association such as the Academy continues to search for the rails of a new direction? An Academy saturated with members gains strength and greater influence on the issues that affect individual physiatrists in each of their specific geographic locations and clinical focuses. The past several decades document the enormous power of individuals who contribute to shared experiences with crowdsourcing in almost every area of life, from the arts, to business, to philanthropy. I suspect members would feel greater confidence by belonging to an Academy more fully permeated by physiatrists, receiving what they want and need in the form of clinical education, advocacy, income security, and camaraderie.
PM&R
So, beyond the governance structure of the Academy, we also must examine ourselves as members. In an ideal situation, every physiatrist would contribute to the Academy to keep it financially and philosophically sound. Still, 30% of our colleagues do not associate the tangential value of the Academy with their personal responsibility to support it. Fortunately, all but the most self-absorbed recognize the limitations of the Academy to respond to their specific needs. We tend to understand the value of compromise and the notion of the greater good. Furthermore, most of us realize the value of belonging to multiple organizations, peeling off just what we need from each one to create a structure that meets our precise needs. The Academy must continue to recognize not only its national but also its local responsibilities. Getting caught in
Vol. 6, Iss. 10, 2014
865
the political uproar has finite value. The Academy is responsible to members’ needs, not just members’ national needs. This distraction will lead to missed opportunities, which, even as they might be hidden, can be tangible losses. The Board of Governors is perhaps the most effective structure that we have to help guide the Academy’s decisions, but we must be aware of its limitations. The Board is made up of imperfect humans with presumptions and viewpoints that are unique. Board members must remain vigilant to their biases and how they impact decisions. They must find humility in a position that risks vanity. As members, we should all assess our expectations of the Academy, viewing it not as an answer to all of our needs but as an entity that requires nurturing by each of us. It remains the best structure we have to promote the values of our specialty and our ability to serve our patients.
