Making the Implicit Explicit

By  |  October 15, 2017 | 

Last month, I wrote about some interesting workplace trends, in particular about how the implied compact between U.S. workers and their employers is evolving rapidly. Few of us in the workforce today can conceive of an employment relationship in which we are guaranteed lifelong employment and a generous benefits package including full healthcare and retirement in exchange for hard work and loyalty to a single employer. Since then, I’ve had several conversations about the term “compact” as I used it in that post. At its most fundamental, a compact is an agreement between two or more parties. In my recent post, I used the term to refer to the generally accepted but rarely articulated set of expectations that workers and their employers have of each other.

There is an implied compact between physicians and the hospitals where they practice as well. Historically that compact assumed that doctors would refer lots of patients to the hospital and provide good quality care – as each doctor independently defined it; in exchange, the hospital would provide the resources the doctor wanted, as well as a high degree of professional autonomy and respect and in many cases protection from the business realities of healthcare.

Well, we all know that over the last decade or two, healthcare has evolved in ways that make the traditional expectations that hospitals and doctors had of each other obsolete. This has led to a huge amount of frustration on both sides, and I am especially sympathetic to older doctors (and hospital administrators) who find themselves in a rapidly changing, resource-limited environment that they couldn’t even have conceived of when they first made the decision to go to medical school. My very first hospital administration mentor, a curmudgeonly old COO, told me in 1979, “Leslie, they’re making this so it’s not gonna be any fun anymore.”

Too many organizations that employ doctors haven’t made enough effort to engage their physicians in dialogue about the changes occurring in healthcare and what it means for the expectations that doctors and their employers have of each other. But dialogue is a two-way street, and too many physicians haven’t made enough effort to engage their administrators in dialogue about these issues either. Seems like it’s just easier to let the expectations evolve without talking about them, to blame each other, and to let the mistrust grow.

Fortunately, some healthcare organizations and their physicians have chosen to do the hard work of engaging with each other to understand their respective perspectives of the changing healthcare landscape, and to negotiate a new set of mutual expectations. The result of these efforts is typically expressed in the form of a written “Physician Compact.” There are lots of examples of these documents on the web, including compacts from Memorial Hermann Physician Network, Wheaton Franciscan Medical Group and the one from Virginia Mason Medical Center below that I found doing a simple search.

The most successful physician compacts have the following characteristics:

  • They are developed as a collaborative effort between staff physicians and organizational leaders, not through a top-down process.
  • They clearly express what each set of stakeholders has the right to expect from the other; some provide both a list of what each stakeholder group should expect to give, and what that stakeholder group can expect to receive from the other.

  • They are written in concrete language that focuses on observable behaviors and demonstrable outcomes.
  • They are forward-looking and anticipate how healthcare will continue to evolve, while still being applicable today.
  • Both groups of stakeholders are committed to upholding the compact, and to holding themselves and each other accountable for behaving in ways that are consistent with it.

If the organization you work for doesn’t have a physician compact, you might consider approaching your hospitalist group’s leaders or organizational leaders about the idea of undertaking a collaborative process to develop one. The compact framework can be valuable for other applications, as well. You might consider developing a hospitalist – hospitalist group leadership compact within your hospitalist group, or a hospitalist physician – NP/PA compact to articulate the expectations that the doctors and NP/PAs should have of each other. I have seen some groups use the compact framework to document their co-management relationships with other specialties such as orthopedic surgery or cardiology.

I haven’t yet been able to find any literature documenting the actual impact of a physician compact on an organization’s performance or its physician relationships. If you are a physician (or an institutional leader) working in a setting where a written physician compact is in place, I’d love to hear about your experience with it. Do people take it seriously? Does it guide behavior and decision-making? Has it made a difference in the relationships between physicians and administrators in your organization? Please feel free to post a comment on this blog.


  1. Avatar
    Dean Gushee, MD August 2, 2018 at 4:11 pm - Reply

    What I cannot seem to find explicitly, is what organizations actually ‘use’ the compact for. I’m interested in how a compact becomes an explicit part of an annual performance evaluation for example. I see many say that they use it that way. But, exactly how? Is it merely a gestalt evaluation of a providers buy-in? Is it used to score and rate a provider? All of these are really an expression of the ‘culture’ of the organization. As such, it should somehow be part of a review to determine if a provider is embracing the ‘culture’. But, what does that mean and how is it actually used. I’d be interested to hear what you’ve found out.

  2. Leslie Flores
    Leslie Flores August 3, 2018 at 1:07 pm - Reply

    Hi Dean, thanks for your comment – it raises important questions that deserve a more thorough response than I can provide here. First (and possibly foremost) there is incredible potential value just in the process of two parties engaging with each other to discuss the issues underlying their differences and to negotiate the compact. It creates a platform for building relationships and common understandings that can last well beyond the compact-development process.

    Beyond that, the short answer is that the more specific and explicit you can make the terms of the compact, the more opportunities there are to use it. Groups and organizations can use the compact in a variety of ways. One would be to build compact terms into their respective mission/vision/values statements. Certainly the compact would be helpful in new hire orientation and onboarding (potentially even in the recruitment process) as a way of setting expectations. Compact terms can be incorporated into the group’s problem-solving and decision-making processes (“Is this proposed resolution or decision consistent with the commitments we’ve made in our compact? How do our choices support (or not) our compact commitments?). And as you suggest, compact terms – if specific enough – can be incorporated into both individual and group-level performance evaluations; one great way to do this is through peer and 360-degree evaluations in which others confidentially evaluate the individual or group on how consistently they live the values of the compact. The group members could similarly evaluate the organization on its performance living up to the compact.

    Thanks again for the comment – as you can see, you’ve given me fodder for my next blog post!

    — Leslie

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About the Author: Leslie Flores

Leslie Flores
Leslie Flores is a founding partner at Nelson Flores Hospital Medicine Consultants, a consulting practice that has specialized in helping clients enhance the effectiveness and value of hospital medicine programs as well as those in other hospital-focused practice specialties since 2004. Ms. Flores began her career as a hospital executive, after receiving a BS degree in biological sciences at the University of California at Irvine and a Master’s in healthcare administration from the University of Minnesota. In addition to her leadership experience in hospital operations, business development, managed care and physician relations, she has provided consulting, training and leadership coaching services for hospitals, physician groups, and other healthcare organizations. Ms. Flores is an active speaker and writer on hospitalist practice management topics and serves on SHM’s Practice Analysis and Annual Meeting Committees. She serves as an informal advisor to SHM on practice management-related issues and helps to coordinate SHM’s bi-annual State of Hospital Medicine Survey.


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