"I have worked for organizations that treated health care clinicians like they were widget makers in factories."
Business ownership runs in my family. I come from a long line of individuals who owned clothing stores, boot manufacturers, medical and accounting practices, HVAC businesses, and training firms. When I earned my first undergraduate degree, I minored in business administration. Today, as the founder and CEO of Enlighten Health Care, LLC, I know there is both an art and a science to most things in life—including starting a multidisciplinary group practice.
The science is the finance portion: payroll, rent, utilities, budgeting, advertising, overhead, etc. The art pertains to managerial aspects, human interactions, motivating and exciting others, and the like. However, the art and the science would never have a chance at synergizing if not for the why of the organization. It is truly the why that takes precedence.
That is the driving force of the organization and that is what unites and inspires the team. What inspires me, and the purpose of my organization, is to elevate health care providers and to provide exceptional patient care through great leadership.
Unfortunately, during my career I have seen the antithesis of all 3 of these core values. I have worked for organizations that treated health care clinicians like they were widget makers in factories—always pushing clinicians to make more widgets and sell them for more revenue with an inequitable reward that favors only the organization, with catchphrases such as “no margin, no mission.”
I have seen patient care suffer because of poor organizational policies. I have firsthand experience with organizations with poor leadership and a culture of punishment instead of a just culture. Not only have I experienced problems like this, but I have also heard a plethora of stories from my peers about these same problems, which leads me to believe that this may be a pervasive disease in health care.
There have been more and more instances in the scientific literature surrounding burnout in medicine, and I think a great deal of that is related to organizational culture. A 2018 paper reported that 46% of physicians experience burnout, which leads to an increase in physician errors secondary to, among other things, stressful work.1
It is not just that health care is stressful in and of itself; organizational culture is widely accepted to play a role in job burnout, and burnout is 1 of the factors undermining patient care.2 Enlighten Health Care, LLC, was formed to combat this toxicity.
Forming an organization is much like a painting: I get to decide the medium in which the painting is done; the hues, vibrancy, and opacity of the colors; and the order in which the oils are applied to the canvas. However, this is not something I did alone, and the brushstrokes were not all mine. My father is a man of many proverbs and I was an apt pupil as he would spout them without refrain during appropriate situations. I will quote him now: “Many hands make light work.”
I have a remarkable team of psychiatric and family nurse practitioners, practice managers, finance professionals, and so many more professionals who keep the business running—and honestly, I would not have been able to do it without all their support, sacrifice, and encouragement. Everyone is aligned with the goals of the organization—the why—and everyone behaves with its best interests in mind.
Forming a multidisciplinary group practice was really the best option, since I am a psychiatric mental health nurse practitioner and my wife is a family nurse practitioner. The convergence of our training and disciplines has allowed us and our team(s) to thrive in the marketplace while providing exceptional patient care.
And there is certainly a need for good mental and physical health care. In 2020, more than 1 out of every 5 adults in the United States had some type of mental illness.3 The Centers for Disease Control and Prevention (CDC) reports that more than half of the US population will receive a diagnosis of a mental health disorder during their lives.4
There is a limited number of psychiatrists in the country5 and their numbers are declining.6 The numbers of nurse practitioners, however, are on the rise.7 This means the nurse practitioner is in a perfect place to help with the mental health crisis the country is facing.
Enlighten Health Care, LLC, also has a fundamental desire to develop people. This is something that really inspires me as well. This is not a quote from my father, but during my youth, I had heard that “the path to greatness is surrounding yourself with great people.”
For the longest time, I thought that meant that I had to seek out sages, visionaries, and luminaries and persuade them to let me into their circles—but this is not what it means at all. What it really means is that we should educate, elevate, develop, and inspire those around us. I try to do this not only in business, but in all facets of my life and in many of my interactions with others, as this is core to my being.
However, starting a business is not something that should be done on a whim or out of frustration with a current employer (no matter how real the temptation).
Scour the literature or talk to anyone in business, and you will hear that roughly 20% of businesses fail in the first year, 30% in the second year, and 50% by the fifth year; only 30% will make it a decade or longer. Some research suggests that these failures may be due to problems with cash flow,8 which can lead to owner stress and poor morale in the organization. Starting a business really should be felt in the soul of the leader and with proper planning. The problem is that we cannot plan for everything.
Enlighten Health Care, LLC, was started with more than 2 years’ worth of income, a solid plan with scrutiny of finance, and frequent accounting consults. Still, early on, despite my best planning, it often felt as if no good deed went unpunished and Murphy’s Law the Deity. In any business, early on, there will be challenges, some of which are nearly unbearable.
If one has not properly planned or does not have the fortitude, the fire in the belly, the burning in the soul, the drive, the proper financial plan, and the stress tolerance, the walls will crumble—then one will find themselves resigned to the employ of someone else who did have those characteristics.
Balancing the administrative side with the clinical side is certainly a challenge. In The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing,9 author James M. Dahle, MD, surmises that many physicians choose to work for someone else in order to avoid the administrative burden that operating a practice entails.
However, he also makes the point that working for someone else almost guarantees that you will not be paid your worth. It is a shame that many health care clinicians are opting to work for large organizations just to avoid the administrative aspects of running a business and the legal and regulatory hassles, and instead submit themselves to the will of others for 26 paychecks a year.
Aside from the administrative burden, there is also a call to find the right mix of clinicians, which can be a daunting task. In other types of businesses, roles are often filled with warm and, we hope, more than semi-capable bodies that fill the immediate need of a business. Interviewing individuals to determine their work ethic, their ability to perform their duties, their understanding of the job description, and whether they meet the metrics is 1 thing; however, that is only part of it.
In order to find the right individuals, I interview to determine whether they align with the philosophical underpinnings of the organization—the why. After all, that is what the business is about: its core values, the vision, the success of all the employees, and all the patients we serve. Since the business is about everyone working for a common goal, it is important to find individuals who have the vision of the organization in mind. These are the people I want to see grow, develop, and spread their wings, either within the organization or outside the organization.
I have an undergraduate minor in business administration, and during my time in those classes, I learned about the different management styles: autocratic, democratic, and laissez-faire. If you have not guessed, my business functions primarily as a visionary management style that exists under the laissez-faire framework.
That being said, the clinicians have their own drive and their own will to succeed, and they get support from the organization. These are the individuals the business wants: those who want to be at the pinnacle but also recognize when they need the support of an organization. The needs of both the clinicians and the business exist simultaneously and when symbiosis is present, the system works well.
There are a few things I wish I had known before I started the journey of business ownership. The first is that insurance contracts often require someone be on call, and by someone, that means a human being answers the phone 24/7. Additionally, I wish I knew how long it actually takes to credential with insurers. Three to 6 months may be the average, but there will be outliers. One of the things I was not prepared for was the actual amount of stress of starting a business. You simply cannot prepare for all the things that can inevitably not go according to plan.
For instance, we once had a problem with email that was constantly being flagged as spam by the email provider—so outbound emails would never go through. Thankfully, I know the best IT guy on the planet (here is a plug for you, FG). I was lucky because I am very organized; however, things you may organize together may need to be organized individually. I initially lumped all the insurance contracts into 1 folder but I quickly realized that this needed amending because contracts deserve and require individualized homes.
The practice is also on the border of 2 other states so sometimes it can be difficult for out-of-state insurers to recognize that you do not follow the laws and code of their home state; instead, you follow the rules of the practice’s home state and location. I also did not anticipate how much time dealing with regulatory (which is a kind way of saying “bureaucratic nonsense”) items would take.
For the machine to fire on all cylinders, with greased cogs turning smoothly, running a business takes a tremendous amount of time management, organizational skills, and sacrifice. Personally, I dedicate time for both patients and administration with a healthy dose of rigor, structure, tenacity, and planning—often months in advance. If something does not get done (usually some of the admin), then it is usually completed outside normal business hours when familial obligations have subsided.
There are a lot of individuals who think owning a business allows you not to work, but this is a fairy tale and the opposite of fact. There is nothing better than being self-employed: You can work half-days, and nobody cares in which 12 hours you do it.
Mr Schreiber is a psychiatric mental health nurse practitioner and founder and CEO of Enlighten Health Care, LLC, in Wheeling, West Virginia.
1. Samra R. Empathy and burnout in medicine-acknowledging risks and opportunities. J Gen Intern Med. 2018;33(7):991-993.
2. Montgomery A, Todorova I, Baban A, Panagopoulou E. Improving quality and safety in the hospital: the link between organizational culture, burnout, and quality of care. Br J Health Psychol. 2013;18(3):656-662.
3. Key substance use and mental health indicators in the United States: results from the 2020 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. 2021. Accessed January 4, 2023. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf
4. About mental health. Centers for Disease Control and Prevention. Reviewed June 28, 2021. Accessed January 1, 2023. https://www.cdc.gov/mentalhealth/learn/index.htm
5. Beck AJ, Page C, Buche J, et al. Estimating the distribution of the US psychiatric subspecialist workforce. University of Michigan School of Public Health Behavioral Health Workforce Research Center. December 2018. Accessed January 2, 2023. https://www.behavioralhealthworkforce.org/wp-content/uploads/2019/02/Y3-FA2-P2-Psych-Sub_Full-Report-FINAL2.19.2019.pdf
6. The psychiatric shortage: causes and solutions. National Council for Mental Wellbeing. Updated March 1, 2018. Accessed January 4, 2023. https://www.thenationalcouncil.org/resources/psychiatric-shortage-causes-and-solutions/?gad=1&gclid=Cj0KCQjwsIejBhDOARIsANYqkD1UpI9FhyCQPsaqbbYe1LBzu08RFOIfUYVpGuFhingNQwkruROuwrwaAjrKEALw_wcB
7. Behavioral health workforce projections, 2017-2030. Health Resources and Services Administration. Accessed January 3, 2023. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/bh-workforce-projections-fact-sheet.pdf
8. Gustafson K. The percentage of businesses that fail and how to boost your chances of success. LendingTree. Updated May 2, 2022. Accessed January 2, 2023. https://www.lendingtree.com/business/small/failure-rate/#:~:text=20.8%25)%20industries.-,Percentage%20of%20businesses%20that%20fail%20in%20the%20U.S.,LendingTree%20analysis%20of%20BLS%20data
9. Dahle JM. The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing. WCI Intellectual Property, LLC; 2014.