President's Page

President's Page
May 2005

No Margin, No Mission—
Physicians and the Community

by Leslie H. Secrest, MD
2005 DCMS President

The saying, “No mission, no margin; no margin, no mission,” has been on my mind for a while. This phrase, although simplistic, represents forces that begin with us at birth and persist to the grave. Mission and margin are two factors that affect us as individuals, as members of organizations, and as members of communities. As we grow from child to adult, our parents and teachers help move us steadily toward finding our life’s goal (mission) and understanding the significance of costs (margin) in everyday living. Our mission in life often affects our identity and self-esteem. Choosing to practice medicine clearly is such a moment in most physicians’ lives.

Communities undergo a similar experience. Communities that have a mission are organized, purposeful, and focused. They have their priorities straight. But having an appropriate mission does not guarantee success. Remember, no margin, no mission. Even our greatest passions must produce results, a tangible “profit.” Thus, margins also can affect the way we judge ourselves and the way society judges us.

You and I work each day to fulfill our goal as a physician. We practice, teach, or support medicine’s goals in other ways for the benefit of patients. We want the community to find value in our work. How the community perceives our mission will affect our ability to produce a margin. I believe that patients in Dallas County value the services of physicians and hospital systems. Many people value and support our mission, but the margins are growing thin—so much so that some of us are forced to re-evaluate our mission. The struggle between mission and margin grows. Does one count more than the other?

There is a balance between mission and margin that is like the dynamic of forces required to ride a bicycle at various speeds through a series of turns. At different times life requires more emphasis on mission and less on margin, and vice versa, but at no time does one exist without the other. Without balance the results of the mission cannot be obtained and sustained over time. As individuals or as groups, we need the self-esteem produced by our missions to have enjoyment, satisfaction, and serenity. The satisfactions often will be passed on to others in such a way that we move and develop from one generation to the next within a community and society capable of solving life’s dilemmas.

An organization, just like each of us as individuals, must evaluate its place in a community and society. Positive values within the organization and society are necessary to sustain the organization. Mission and margin can bring forth the most intense suspicions, fears, and anxieties with the leaders of organizations. Yet these same pressures produce the most astounding accomplishments, community pride, and individual satisfaction. Physicians are leaders in the community and we share a mission of improving the health of our communities. Through this mission, we seek a margin that will sustain us as individuals, as families, as institutions, and as communities. Each of us is highly sensitive to these forces, and we must continually assess the changes and assumptions about how this will affect our mission and our margin.

For example, as a psychiatrist, I pay attention if a psychiatrist leaves or enters the community, as this change might affect my personal mission and margin. I also make assumptions as to how that change will affect the institutions with which I am associated.

The very nature of mission and margin, with its close relationship with economic survival, implies competition. Yet it is imperative that we not overlook the community’s mission—to be healthy and productive. Understanding this tension and the survival of our practice, it is especially important that we treat each other respectfully. Competition among us and our institutions produce change, not extinction. We must define our community, identify our competition, and understand the nature of the competition.

Walt Kelley’s comment from Pogo, “We have met the enemy and it is us,” might apply. Often our definition of community is too narrow or our competition is too local or what constitutes an effort to improve health is too exclusive. We need to look at the bigger picture. Let me explain: In talking to a physician friend who does basic research, his competition may be local, involving other local institutions or another department in his institution. But, just as importantly, his competition is with others at a national and international level. While my friend seeks to survive in the research world, his local competition can be managed in an atmosphere of collaborative competition furthering the development and evolution of the competitors. In this situation competition is healthy for all concerned. Healthy competition in health care benefits patients.

Another example of competition that involves the community is the realization that a capitated Medicaid delivery system would allow a state agency to achieve its perception of a legislative mandate but would severely impact the mission and margins of local healthcare institutions and the local tax-paying community. At a local level, we may view the mission and margin of Dallas County being squeezed. We have difficulty understanding how this process is improving the health of the community.

Lack of understanding of each other’s mission and margin seems to result from a failure to communicate. One of my mentors occasionally reminds me that if someone disagrees with me, the problem lies with my inability to adequately and persuasively communicate my position. This is why dialogue among physicians, institutions, and our community is important. The Dallas County Medical Society plays a key role in such dialogue. We seek to help local healthcare leaders balance the pressures of mission vs margin.

Mission and margin are balanced to provide an effective, sustainable, and dynamic healthcare system in Dallas County. This system fosters growth, development, and evolution of all parties. For many years DCMS has worked to balance the mission/margin equation for physicians and our community. Such work will be needed for years to come.

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